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The relevance of high reliability theory (HRT) to reliabilty-seeking organizations (RSOs)

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Title:
The relevance of high reliability theory (HRT) to reliabilty-seeking organizations (RSOs)
Creator:
Al Nizami, Amir Khaled
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English
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xviii, 274 leaves : ; 28 cm

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Reliability -- Case studies ( lcsh )
Reliability ( fast )
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Case studies. ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )
Case studies ( fast )

Notes

Bibliography:
Includes bibliographical references (leaves 258-274).
General Note:
Administrative Leadership and Policy ; School of Education and Human Development
Statement of Responsibility:
by Amir Khaled Al Nicami (Bani Mustafa).

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University of Florida
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ocn747428669
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LD1193.E3 2011d A56 ( lcc )

Full Text
2
THE RELEVANCE OF HIGH RELIABILITY THEORY (HRT) TO RELIABILITY-
SEEKING ORGANIZATIONS (RSOs)
by
Amir Khaled A1 Nizami (Bani-Mustafa)
B.S., University of Colorado Denver, 1998
Business Management
Human Resources Management
M.S., Keller Graduate School of Management, 2004
Masters of Business Administration (MBA)
Masters of Project Management (MPM)
A thesis submitted to the
University of Colorado Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
2011


This thesis for the Doctorate of Philosophy
degree by
Amir Khaled A1 Nizami (Bani-Mustafa)
has been approved
Rodney Muth
7
Sarah Kovoor-Misra
oZ//L/zo\\
Date


Amir Khaled A1 Nizami (Bani-Mustafa) (Ph.D., Educational Leadership and Innovation)
THE RELEVANCE OF HIGH RELIABILITY THEORY (HRT) TO RELIABILITY-
SEEKING ORGANIZATIONS (RSOs)
Thesis directed by Connie L. Fulmer, Ph.D., Professor, Administrative Leadership and Policy
Studies
Abstract
The purpose of this study was to explore the relevance and applicability of high reliability
theory (HRT) to reliability-seeking organizations (RSOs) and organizations in the
mainstream (MOs). RSOs are tightly coupled organizations that operate in a competitive and
rapidly changing environment and have little time to respond to unexpected events. In the
absence of a theory for sustained high performance (Kirby, 2005) in MOs, room exists for
testing the use of HRT theory as a model or metaphor for improving reliability in non-HROs.
Until now, only a few studies of RSOs provided initial evidence on the relevance and
applicability concept of HRT theory to non-HROs. The present mixed-method case study
selected Dish Network L.L.C and EchoStar Communications, two RSOs, as the research
settings to study the relevance and applicability of HRT theory. While four research
questions and two hypotheses are detailed in the study, one main research question guided
this work: To what extent have Dish Network/EchoStar Communications, two RSOs,
manifested the HRT principles? Data collection methods included (a) the administration of an
HRO Perception Scale Survey (Barrett et al., 2006) to employees of Dish Network and
EchoStar in Colorado, (b) the identification and analysis of organizational artifacts, and (c)
the transcriptions of interviews conducted in a pilot study. The study findings are organized
by research question with excerpts from the analyses of organizational artifacts and
transcribed interviews showing how both organizations manifested the HRT principles in
their operations. The HRO Perception Scale Survey revealed that employee perception of
risk and organizational response to risk in both organizations is similar to that of employees
in HROs and other RSOs. The analyses of the organizational artifacts and transcribed
interviews revealed that Dish Network and EchoStar manifest the HRT principles via various
HRO artifacts. These specific artifacts are sorted first by HRT principle and secondly as
being central or tangential to that principle. The triangulation of quantitative and qualitative
data provides empirical evidence that supports the relevance and applicability of HRT to
RSOs in this study. Implications of findings for theory, practice, and future research are
presented.
This abstract accurately represents the content of the candidates thesis. I recommend its
publication.
Signed
Connie L. Fulmer


DEDICATION PAGE
First, I dedicate this work to my mother and father, Khaled and Fatima A1 Nizami. I
am thankful to both of you for bringing me to this world, and for helping me see the light at
the end of so many dark tunnels in my life. Your words of wisdom and encouragement never
stopped ringing in my ears. They have become a part of my culture, one I will adore, believe
in, and be loyal to until my heart stops beating.
Secondly, I dedicate this work to my wife Noor, and my sons Amour and Bashar.
Your support of my work in this PHD program has been crucial for my successnot only
when I had to be away at class, but also when I spent hours at my computer, both during the
program and through the entire dissertation processand I thank you for it.
Thirdly, I dedicate this work to my oldest brother, Dr. Mohamed Nezami (PHD), for
charting the way for me and his other brothers to succeed in life. Your accomplishments,
leadership, and encouragement have all played a huge role in keeping us connected in with
reality, ourselves, all the good in this world, and, more importantly, for the idea of believing
in Higher Education and giving back to our community and the rest of the world. I also
dedicate this work to my brothers Omar, Ali, Authman, Mustafa, Khaleel, and Aatedal.
Finally, I dedicate this work to not only my tribe Bani-Mustafa and the more than
7,000 members who are known for their wisdom, bravery, and heroism, but also to my
homeland Jordan.


ACKNOWLEDGMENT
First, I would like to acknowledge my chair, Dr. Connie Fulmer (PFID), Professor of
Administrative Leadership and Policy Studies at the University of Colorado Denver, for her
knowledge, wisdom, dedication, and patience in helping me get through the entire program.
As hard as it was at times during the past five years, your vision of what it would take to
complete this work guided me to the finish line. I also would like to acknowledge my other
committee members, Dr. Rodney Muth (PHD), Professor of Administrative Leadership and
Policy Studies at the University of Colorado Denver, for his support and guidance through the
coursework and the dissertation processes. I would like to thank Dr. Dorothy Garrison-Wade
(PHD), Assistant Professor of Administrative Leadership and Policy Studies at the University
of Colorado Denver, for her guidance and endless support throughout the entire program.
Last but not least, I would like to thank Dr. Sarah Kovoor-Misra (PHD), Associate Professor
at the School of Business at the University of Colorado Denver, for expertise, guidance, and
support during the proposal meeting that charted the way for me to improve the study that I
had originally planned. I appreciate the fact that you served on my committee and am
thankful for the opportunity to have worked with you.
Additionally, I would like to thank Dr. Michael Scott Barrett (PHD) at South Dakota
State University for his generous support and guidance, and for the time he spent talking with
me on the phone giving feedback about my work. I also would like to thank Dr. Kathleen
Sutcliffe (PHD), author and one of the HRO pioneers at the University of Michigan, for


taking the time to be interviewed by me during the literature-review period. Your knowledge
helped me narrow my research questions and to identify the knowledge-gap in the literature.
There are several other key players at Dish Network and EchoStar that I need to
thank. The first is Rex Povenmire, Vice President of Corporate Initiatives at Dish Network,
for helping me obtain the required permissions to conduct this research study, and in
gathering survey data from both Dish Network and EchoStar. I also thank Michael Dugan,
President of EchoStar Communications, for being very supportive of my research efforts. I
must also thank Bemie Han, Executive Vice President and Chief Operating Officer at Dish
Network, for providing support and guidance during the data collection process of the study.
Finally, I thank Michael Kelly, Executive Vice President, and Thomas Cullen, Executive
Vice President at Dish Network for their assurance of support when and where needed.
Finally, I acknowledge the victims of 9/11, Hurricane Katrina, The Gulf Coast
disaster, and all tragic events around the world, those that are natural or man-made. I hope
this work will pave the way for many mainstream organizations and reliability-seeking
organizations to capitalize their efforts in the areas of preoccupation with failure, reluctance
to simplify, sensitivity to operations, commitment to resilience, and deference to expertise, in
order to improve the reliability outcomes of their organizations and keep us safe, healthy, and
prosperous.


TABLE OF CONTENTS
List of Figures...................................................... xvi
List of Tables.......................................................xvii
CHAPTER
I. INTRODUCTION.........................................................1
Statement of the Problem.........................................3
Purpose of the Study.............................................4
Research Questions/Hypotheses....................................6
High-Reliability Theory..........................................7
Background......................................................10
Significance of the Study.......................................12
Researcher Bias and Stance......................................13
My Role as an Employee........................................13
Mitigating Bias in Data Collection............................14
Mitigating Bias in Data Analysis..............................15
Study Limitations...............................................17
HRO Perception Scale Instrument...............................17
Sample Size...................................................18
Survey Response Rate..........................................18
Organizational Artifacts......................................19
Research Methodology..........................................19
vii


Study Assumptions...................................................20
Operational Definitions.............................................21
Summary.............................................................24
II. REVIEW OF THE LITERATURE...............................................25
Organizations.......................................................25
Organizations as Complex Open Systems............................26
Four Organizational Designs......................................29
Organizational Performance Background............................30
Literature Review on HPOs...........................................33
Defining HPOs....................................................35
Characteristics of HPOs..........................................37
Leadership and Culture in HPOs...................................39
Transitioning to HPO Status......................................41
Sustaining High Performance in the Long-Term.....................45
Summary of HPO Shortcomings......................................47
HPO Theory at the Crossroad......................................48
Literature Review of HROs...........................................51
History of HROs..................................................51
History of Normal Accident Theory (NAT)..........................52
History of High Reliability Theory (HRT).........................56
NAT vs. HRT Perspectives.........................................58
viii


Defining, Measuring, and Validating Reliability...................61
Characteristics ofHROs............................................65
Complexity in HROs................................................71
HRO Relevance to Non-HROs.........................................71
Decision Making in HROs...........................................72
Achieving High Reliability in HROs................................74
Leadership, Teamwork, and Trust in HROs...........................74
Culture as a Source of Reliability in HROs........................80
Validating the HRO Model..........................................83
Summary ofHROs....................................................87
Literature on HRT Relevance to Non-HROs-
Knowledge Gap.......................................................90
Justification for Selecting Dish Network and
EchoStar Settings...................................................92
Summary of Literature Review........................................95
III. METHODOLOGY............................................................98
Purpose of Study....................................................98
Research Questions..................................................98
Research Design.....................................................99
High Reliability Perception Scale Instrument.......................100
HRO Perception Scale Reliability.................................101
HRO Perception Scale Validity....................................103
ix


Organizational Reliability-Seeking Artifacts...........................103
Value Added (Similarities/Differences).................................104
Study Participants, Selection of Participants,
and Settings...........................................................104
Study Participants..................................................105
Selection of Participants...........................................106
Description of Study Settings.......................................107
Data Collection and Analysis Processes.................................108
Research Question 1 Data Collection.................................109
Research Question 1 Data Analysis...................................111
Research Question 2 Data Collection.................................112
Research Question 2 Data Analysis...................................113
Research Question 3 Data Collection.................................118
Research Question 3 Data Analysis...................................118
Research Question 4 Data Collection.................................120
Research Question 4 Data Analysis...................................120
Pilot Study............................................................122
Pilot Study Data Collection.........................................122
Pilot Study Data Analysis...........................................123
Reliability and Validity of Qualitative Data
and Data Collection....................................................126
Trust Worthiness and Credibility.......................................127
x


Summary of Methodology............................................128
IV. FINDINGS.............................................................129
Research Question #1...............................................129
Discussion of Overall Survey Results and Rational..................132
Self-Efficacy Sub-Scale.........................................132
Organizational Risk Sub-Scale...................................135
RQ1 Hypothesis # 1.................................................139
Summing Dish Network Responses for
the HRO Perception Scale........................................143
RQ1 Hypothesis #2..................................................144
Summing EchoStar Responses for the HRO
Perception Scale................................................148
Research Question #2...............................................149
Preoccupation with Failure.........................................152
Artifacts Central to Preoccupation with Failure.................152
Artifacts Tangential to Preoccupation with Failure..............161
Reluctance to Simplify.............................................166
Artifacts Central to Reluctance to Simplify.....................167
Artifacts Tangential to Reluctance to Simplify..................171
Sensitivity to Operations..........................................175
Artifacts Central to Sensitivity to Operations..................177
Artifacts Tangential to Sensitivity to Operations...............186
xi


Commitment to Resilience
188
Artifacts Central to Commitment to Resilience .................189
Artifacts Tangential to Commitment to Resilience...............193
Deference to Expertise............................................195
Artifacts Central to Deference to Expertise....................196
Artifacts Tangential to Deference to Expertise.................197
Organizational Error Reporting....................................199
Call-in-Rate (CIR).............................................200
Customer Service Satisfaction SurveyCSAT......................201
Employee Issues................................................202
Uplink Centers.................................................203
Workplace Safety...............................................205
Summary of RQ2 Findings...........................................205
Research Question # 3.............................................206
Anticipation Strategies ..........................................206
Preoccupation with Failure.....................................207
Reluctance to Simplify.........................................209
Sensitivity to Operations......................................210
Containment Strategies............................................211
Commitment to Resilience.......................................211
Deference to Expertise.........................................212
xii


Summary of RQ3 Findings.........................................213
Research Question #4............................................214
Preoccupation with Failure....................................215
Reluctance to Simplify........................................215
Sensitivity to Operations.....................................215
Commitment to Resilience......................................216
Deference to Expertise........................................216
Summary of Findings.............................................217
V. CONCLUSIONS, IMPLICATIONS, RECOMMENDATIONS ........................219
Conclusions.....................................................219
Implications for Theory.........................................223
New Hybrid Model .............................................223
HRT Principles as a Safety Bridge for All Organizations.......225
Benefits of a Collective Intelligence within the Organization.227
Implications for Practice.......................................229
Managing the Unexpected for an Individual.....................229
Implications for HROs and RSOs................................230
Implications for Non-Business Organizations Such
As Schools....................................................231
Implications for Business and the Idea of Competition.........233
xiii
Recommendations
234


A Synthesis of HPO Characteristics toward a Viable
HPO Model......................................................234
Study of HRO Perceptions Using Employee Types as Unit
of Analysis....................................................235
Study of Leadership in RSO Organizations.......................236
Change in Theoretical Framework Language in Future
Studies .......................................................236
Replication of this Study with Addition of Interviews
to Methodology.................................................236
Triangulation of Future Study Results with
Previous Research..............................................237
Conducting Future Research in MOs.............................237
Summary...........................................................238
xiv


APPENDIX
A. Elements of Shared Mindfulness and Forms of Mindlessness..............240
B. Blanchard HPOs Model and Characteristics.............................241
C. The AMS Model of High Performance Organizations (HPOs) ...............242
D. Popovich s Eight Principles of HPOs.................................243
E. Perrows Tightly and Loosely Coupled Systems Characteristics..........244
F. Perrows Antecedents to Accidents and Carrier Responses
to Them...............................................................245
G. Shrivastavas Antecedents to Accidents and Carrier Responses
to Them...............................................................246
H. Reliability Drivers (Bigley & Roberts, 2001)..........................247
I. Ericksen and Dyer (2005): The Eight Human Resources
Practices in HROs.....................................................248
J. Research Introduction Letter..........................................249
K. Demographic Information Questions.....................................251
L. HRO Perception Scale Instrument.......................................252
M. Survey Invitation Email...............................................253
N. Survey Participation Reminder Email...................................254
O. HRO Perception Scale by Sub-Scale.....................................255
P. Dish Networks Employee Award Type and Description....................256
Q. EchoStars Employee Award Type and Description........................257
REFERENCES .....................................................................258
xv


LIST OF FIGURES
Figure
1 Five Processes to Produce Mindfulness and Long-Term Success.............10
2 Elements of Reliability Culture in HROs.................................82
3 Dr. Dish s Career and Training Path..................................157
4 Dish Networks Customer Complaints Trend 2005-2010...................157
5 Total Dish Networks Technical Trouble Calls 2009-2010................166
6 Dish Networks Improvement Idea Dash Board...........................168
7 Dish Network/EchoStars Employee Performance Evaluation Model........175
8 Dish Networks Call-In Rate Dash Board...............................201
9 Dish Networks Call Center CSAT Progress Chart.......................202
10 Number of Technological Related Failures at Dish Network/EchoStar......208
11 Number of Equipment Failures at Dish Network/EchoStar..................208
12 Performance Rank for MOs, HPOs, RSOs, and HROs in the Study............225
xvi


LIST OF TABLES
Table
1 Weick & Sutcliffes Principles (Characteristics) of High Reliability
Organizations (HROs).............................................................5
2 Related High Reliability Theory (HRT) and Organizational Types
and Definitions.................................................................22
3a History of Research on Organizational Performance Literature
by Author 1982-1995.............................................................32
3b History of Research on Organizational Performance Literature
by Author 2000-2005.............................................................32
4 Comparison of Traditional MOs and HPOs..........................................34
5 Key Performance Drivers in HPOs by Attribute by Literature
References......................................................................38
6 Summary of HPO Characteristics in the Literature................................39
7 HRT vs. NAT Regarding Reliability in HROs.......................................59
8a Characteristics of HROs in the Literature 1989-1997.............................69
8b Characteristics of HROs in the Literature 2001 -2008............................69
9a How HROs Manage for Reliability by Author 1990-2001 ............................75
9b How HROs Manage for Reliability by Author 2005-2008.............................76
10 Weick & Sutcliffe, 2001: Sources and Types of Organizational Culture............84
11 Attributes/Characteristics of RSOs in the Literature............................85
12 Summary and Comparison of Critical Organizational Characteristics
in the Study....................................................................88
12 Summary and Comparison of Critical Organizational Characteristics
in the Study (continued)........................................................89
XVII


13 HRO Perception Scale Questions by HRT Principle............................102
14 Open Coding Labels and Categories that Emerged from Dish
Network and EchoStar.......................................................115
15 Axial Coding Categories and Sub-Categories that Emerged from
Dish Network and EchoStar..................................................117
16 Matrix of HRO Practices Found at Dish Network and EchoStar and
in the Literature..........................................................119
17 Matrix of RSO Attributes Found at Dish Network/EchoStar and
in the Literature..........................................................121
18 Open Coding Labels for Pilot Research Interviews at Dish
Network and EchoStar.......................................................125
19 Axial Coding of Pilot Interviews: Sources of Reliability at Dish
Network and EchoStar.......................................................126
20 Participation of EchoStar/Dish Network Survey Respondents by
Office Location............................................................130
21 Breakdown of Manager and Non-Manager Study Respondents by
Office Location............................................................130
22 HRO Perception Scale Data from the Dish Network and EchoStar Study.........131
23 HRO Perception Scale Results by HRT Principle..............................139
24 HRO Perception Scale Data for Dish Network Employees.......................140
25 HRO Perception Scale Data for EchoStar Employees...........................145
26 Organizational Artifacts and Descriptions for Dish Network and
EchoStar Organizations.....................................................150
27 HRO-Like Practices Manifested in Both Dish Network and EchoStar
Organizations..............................................................151
28 Most Distinguished RSO Practices at Dish Network and EchoStar..............218
xviii


CHAPTER I
INTRODUCTION
On a clear bright day, we awoke up to the voices of family members, relatives, and
friends shouting turn on your TV set and watch the news. That day was September 11,
2001, a day that changed America and the world forever. Rebounding from shock was very
harsh and painful. The United States government and the American people paid a dreadful
price financially, socially, and emotionally. The trail of unexpected events continued with
more catastrophes following.
Most recently, off the Coast of Louisiana, an undersea oil well exploded, pouring
thousands of gallons of crude oil into the sea destabilizing and polluting human and wild-life
environments. A manufacturing flaw resulted in many deaths and prompted a massive recall
of Toyota cars. Finally, a military doctor, with a great reputation and potential, killed and
wounded more than 30 soldiers at his own military camp in Fort Hood, TX.
In addition, there have been near misses when tragedy was narrowly averted. A
terrorist aboard an airliner failed to ignite a bomb he was carrying. Had the bomb exploded,
it would have killed the more than 300 passengers. More recently, there was another near
miss when a bomber tried to ignite a car bomb in New Yorks Time Square. Had the bomb
exploded, it would have caused yet another catastrophe in a city still recouping from the
unforgettable 9/11 tragedy.
These and many other accidents around the world had this in common: They shared
similar characteristics and dreadful conclusions. In each event, a father, a mother, a brother,
1


a sister, a best friend, a city, a mayor, a governor, and a country suffered the consequences of
losing a loved one and a citizen, a place they once called home, or a financial catastrophe
resulting in tragedy for many people. The characteristics preceding these accidents may have
been hidden to organizations and institutions with policies focusing on short-term gain.
With every social, technological, political, environmental, and cultural change, our
world and our organizations increase in complexity (Krieger, 2005). We live in an era in
which managing the unexpected is becoming a way of life. Thus, it is no secret that many
organizations including schools and Higher Education Institutions are experiencing
managerial, financial and structural problems (Mohrman & Wohlstetter, 1994). Nowadays,
one only needs to browse the newspapers business section or the Internet to find a plethora
of information explaining the scale of financial and structural problems challenging many
companies and institutions. The examples cited earlier and the current financial crisis, which
followed the collapse of Enron, WorldCom, and AIG, are examples of organizations that
failed to be mindful of their environment, and therefore were unsuccessful managing the
unexpected when it finally struck them. The same is said to be true of educational institutions
(Leithwood, 1982; Witziers, 2003), for example, where low student-achievement scores
provide evidence that today's schools are not prepared to face the many challenges brought
about by a web of political and social factors.
The problem of failing to see the signs of impending failure continues in most
organizations today despite the large number of organizations failing repeatedly for the same
reasons. Many organizations are not learning from these failures, are not attempting to
employ successful risk mitigation, and are not effectively implementing reliability processes
2


associated with what has come to be known as high performance high reliability
organizations (HROs).
Statement of the Problem
Many organizations are not learning all they can from their failures (Tucker &
Edmondson, 2003). This intensifies when there is neither a management culture of reporting
failure or near-misses nor a management culture that encourages employees to report errors
and failures without fears of retaliation or punishment. Detecting and reporting errors, near
misses, and failures and learning from them helps HROs manage the unexpected and remain
reliable and failure free for lengthy periods. In light of the increasing technological
complexities and the unending and intensifying social, economical, and political changes and
challenges, organizations are vulnerable to failure, and thus are increasingly becoming
reliability-seeking organizations (RSOs) (Barrett, Novak, Venette, & Shumate, 2006;
Venette, 2003; Weick & Sutcliffe, 2001).
It has been documented that since inception HROs have been able to avoid
catastrophes and operate in a high reliability mode because they enact mindfulness processes
that help them constantly detect and halt errors in the development stage. This is how,
despite all the challenges and changes within and outside their systems, they are able to
achieve and maintain high reliability and high-performance status and rebound from
shocksomething many organizations in the mainstream (MOs) have a hard time doing.
This process of mindfulness, or the ongoing scrutiny of the unexpected and continuous
refinement of expectations (Weick & Sutcliffe, 2001), helps employees and organizations
avert incidents, accidents, or catastrophes. People who persistently rework their categories
and refine them, differentiate them, update them, and replace them notice more and catch
3


unexpected events earlier in their development. That is the essence of mindfulness (Weick
& Sutcliffe, 2001, p. 46).
What is not strongly generalizable today is whether or not high-reliability theory
(HRT) hallmarks are at work in RSOs that share HROs goals and objectives. This study
explores HRT theorys relevance for other organizations. A small number of studies
documented the theorys relevance to RSOs, providing initial evidence they emulate the best
practices of HROs (Barrett et al., 2006; Barrett, 2008; Venette, 2003; Vogus & Welboume,
2003).
Those practices are grouped in five hallmarks (Weick & Sutcliffe, 2001) found in
multiple HROs, and that form the foundation and the principles of HRT (see Table 1): (a)
preoccupation with failure, (b) reluctance to simplify interpretations, (c) sensitivity to
operations, (d) commitment to resilience, and (e) deference to expertise. HRO literature
provides evidence that when these five hallmarks are at works in an organization, the
organization is considered an HRO. However, studies on the theorys relevance have been
explored only in few small RSOs. Findings from that research indicate that while RSOs do
not employ high-hazard technologies or are exposed to the high level of risk seen in HROs,
they do find themselves in a rather tightly coupled, complex, and changing environment
(Barrett et al., 2006; Venette, 2003; Novak, 2006). Because of that, they go through ongoing
design and redesign stages to ensure their processes are flexible, mindful, and able to deal
with failure.
Purpose of the Study
The purpose of this study is to provide evidence on the HRTs relevance beyond its
traditional use in high complex and tightly coupled organizations known as HROs. Using
4


Table 1
Weick & Sutcliffes Principles (Characteristics) of High Reliability Organizations (HROs)
Principle Description Literature
Preoccupation with failure Focus on predicting and eliminating errors rather than reacting to them. A near miss is a sign of failure not a sign of success Merriam, 2005; Reason, 2000; Roberts 1990; Weick & Sutcliffe, 2001
Reluctance to simplify interpretations Create a state of mind a mindset in every employee that helps them capture the big picture and maintain a comprehensive system awareness Bolman & Deal, 1991; Roberts 1990; Weick & Sutcliffe, 2001
Sensitivity to operations Maintain strong contact between employees, especially front-line employees, to make sure anomalies and problems are quickly identified and dealt with Clarke, 2003; Roberts 1990; Weick & Sutcliffe, 2001
Commitment to resilience Engage employees and resources quickly and instantly to contain errors or difficulties that may be seen as potential problems Boyatzis, & McKee 2005a; Roberts 1990; Weick & Sutcliffe, 2001
Deference to expertise Influence employees to work as a team and defer to experts when a situation requires it Baker, 2006; Morey et al., 2002; Roberts 1990; Weick & Sutcliffe, 2001
an HRO Perception Scale Instrument (Barrett, 2008, Venette, 2003), this mixed methodology
case study collected employee perception data from Dish Network and EchoStar employees,
then reviewed data from organizational artifacts and transcribed interviews to triangulate the
survey results. To date, little research has been done to expand the concept of applying HRT
to non-HROs or to support the usability of an HRO Perception Scale Instrument to examine
employee perception of risk and organizational response to risk. These are key factors
5


providing evidence as to whether or not employees of an organization perceive it as an HRO.
Employee perception of an organization as an HRO is critical because a shared mindset and
strong supportive culture have characterized most HPOs and HROs (Holbeche, 2005;
Roberts, 1990; Weick & Sutcliffe, 2001).
Employee perception of an organization as an HRO is also critical because the
creation of a climate that fosters and encourages the HRT principles can happen only through
active-employee engagement. In RSOs such as Dish Network and EchoStar
Communications, the findings will help bridge the gap between employees and
managements perception of risk and organizational response to risk. It will help these
organizations management evaluate training programs and employee behavior toward risk,
and assess whether or not existing efforts to deal with risks enhanced employee perception,
behavior, teamwork, trust, motivation, collaboration, commitment, communication, and
coordination.
The administration of an HRO Perception Scale Survey and triangulating the results
with, (a) in-depth qualitative reviews of organizational artifacts and documents, and (b)
interviews, will provide evidence supporting the concept of successfully applying the HRT in
both RSOs and MOs. Such findings will document and generalize the relevance of HRT
theory beyond strict use in HROs, and will have major implications to organizational theory
literature in general and the applicability of HRT theory to non-HROs in particular.
Research Questions/Hypotheses
A good scientific research design begins with research questions that need to be
answered or a phenomenon that needs to be explained or described (Creswell, 2007). The
6


following research questions and hypotheses guided this study. First: To what extent have
Dish Network/EchoStar Communications, two RSOs, manifestedHRTprinciples?
To answer this question, the following questions and hypotheses were tested.
1. What is the perception of Dish Network and EchoStar employees of risk and
organizational response to risk, two key indicators of whether or not employees perceive their
organization to be an HRO?
To answer question 1, the following hypotheses were tested:
Hi: Employees of Dish Network perceive the organization as an HRO.
H2: Employees of EchoStar perceive the organization as an HRO.
2. What artifacts provide evidence of how Dish Network and EchoStar manifest
HRO principles?
3. Are the reliability-fostering practices at Dish Network and EchoStar the same as
or different from HROs?
4. Are the reliability-fostering practices at Dish Network and EchoStar the same as
or different from other RSOs in the Barrett (2008) WATG study?
These research questions and hypotheses are direct, straightforward, and hold great
value in establishing empirical evidence to support the applicability of HRT beyond
generalizability and use in the traditional high-risk complex organizations known as HROs.
High Reliability Theory
A good research design is one taking into account the availability of an existing
theory in order to support all the theoretical concepts related to the study. Considerable
research has been conducted to address the question of how organizations achieve high
performance. One of the most prominent theories of managing for high reliability outcomes
7


was HRT developed from research conducted at HROs such as nuclear power plants and air
traffic controllers. HRT provides a strong theoretical foundation for the study. The study
connects HROs literature to a broader set of RSOs by emphasizing RSOs operate in
environments similar to those of HROs, which means they are exposed to a higher degree of
risk than organizations in the mainstream (MOs), and employ the same cognitive practices
that make HROs highly reliable and admirable.
The study makes that connection, building on an HPO analysis that concluded high-
performance theory alone is not the answer to achieving the high-performance and high-
reliability outcomes seen in HROs. This is especially important now because we are in an era
in which the world is flat, communication lines are wide open, threats are higher, challenges
are more aggressive, reliability is the goal to survival, and the unexpected is an imminent
threat. HRT theorys relevance to RSOs and MOs then has critical implications to
organizational reliability, survivability, and profitability. Organizations that adopt this model
are doing so in order to remain ahead of the competition and win the battle over the many
threats in their environment. Thus, making strategic decisions about the organizations
design, structure, culture, and decision-making patterns become critical in helping RSOs
achieve and maintain high levels of reliability in a manner similar to HROs.
The HRT model is the conceptual framework adopted in this study. This theoretical
model asserts that certain organizationsHROs that are technologically complex and tightly
coupledremain highly reliable and almost always achieve the reliability levels expected.
They do so by implementing five mindfulness processes: (a) preoccupation with failure, (b)
reluctance to simplify interpretations, (c) sensitivity to operations, (d) commitment to
8


resilience, and (e) deference to expertise. It also suggests the theory is relevant to other
organizational types that are not HROs but share the same goals and objectives.
HRO organizations offer good lessons for all MOs no matter what the goal of the
particular business (Weick & Sutcliffe, 2001). Figure 1 illustrates the relationship between
HRO strategies and the organizations ability to become mindful, able to manage the
unexpected, and achieve the reliability levels expected. HROs manifest high-reliability
principles or the five-mindfulness process in their organizational input via organizational
artifacts (e.g., employee handbooks, organizational mission, vision, and value statements).
By doing so, they develop an informed culture in which employees from the entire
organization work together mindfully to ensure safety and reliability through the early
detection of errors. This results in producing a hyper-vigilant workforce preoccupied with
failure and the need to prioritize safety and reliability over all and any personal gain. This in
turn produces safety and reliability outcomes.
Thus, the study was conducted in organizational sites meeting the description of the
following characteristics: (a) could be defined as RSOs, (b) organizations that employ
moderately or complex technologies, (c) organizations with a tightly-coupled system, and (d)
organizations that operate in a rapidly changing environment. The goal was not to find
organizations that are HROs per se, but rather to find organizations challenged by the same
environmental events and stakeholder demands, and thus are organizations which share
HROs goals and objectives. This allows for a comparative analysis. Dish Network and
EchoStar Communications met this definition, justifying both companies RSO classification.
9


OPERATIONS
/
OUTPUT
INPUT
Preoccupation with failure
Deference to expertise
Reluctance to simplify
Resilience
Sensitivity to operations
Mindfulness
Processes
Mindfulness
Informed culture
Error detection and
mitigation
Reliability, prosperity, and
profitability
Long-term
Success
Figure I. Five Processes to Produce Mindfulness and Long-Term Success
Background
The search for how organizations can best organize their members for high
performance has continued since organizations began. The ongoing weekly announcements
of bank closures and the historical number of firms filing for bankruptcy are all signs of
organizational failures that could have been prevented (Weick & Sutcliffe, 2001). In many
cases, failure could be due to normal problems ignored until they became pressing problems
that could not be fixed (Weick & Sutcliffe, 2001).
Some may ask why so many organizations failed to sustain a reliable performance, or
even just survive, before or after a crisis or catastrophe. What could have helped them
increase their situational awareness and perhaps anticipate what was coming? Was there not
a successful organizational model that could have been replicated in different organizational
and cultural settings to help organizations remain failure free?
10


Due to changes in our social life, advances in technology, the pressing short product
life cycles, workforce availability, globalization, wars, and other pulling forces, organizations
are being tom apart by competing demands. These changes and challenges are causing
hardships to organizations to the extent they have difficulty keeping up current performance
and reliability levels. Under such circumstances, organizations find it hard to stay ahead of
the competition, preserve their market share, or simply remain in business. Linn, Zhao, and
Carley (2006) argue that a crisis will impose a great challenge to organizational performance,
and that no organizational stmcture will guarantee that a HPO will continue to perform. Even
if the organization attempts to restructure during a crisis, it still has to deal with serious
challenges from the outside as well as internal organizational-design traps.
The answers to questions posed above have been sought for many decades. As a
result, there is a body of research in organizational theory to document a repeatable model
organizations can adopt in order to organize for high performance. Chapter II presents an
extensive review of literature related to HPOs and HROs. This review concludes that since
leadership models and traits do not consistently relate to performance (Northouse, 2007), nor
does high performance theory present a long-term and repeatable solution to organizational
reliability and survival (Smart, Tranfield, Deasley, Levene, & Rowe, 2003), the choices for
organizations were limited. Organizations failed because they could not anticipate the
unexpected or lacked the resources or stmcture to deal with it (Weick & Sutcliffe, 2001).
Despite all of this, hope comes from the HRO literature and is beginning to transform
research on organizational theory. Weick and Sutcliffe (2001) suggest that HRT offers
answers to the questions above and, quite possibly, a repeatable organizational model that has
been successfully utilized in HROs, and could perhaps be emulated across different
11


organizational and cultural settings. This suggests that in order to manage organizations
mindfully and achieve and sustain the levels of reliability expected an organization needs to
manifest the HRT principles in its operational processes and artifacts.
However, this alone does not guarantee organizational members will share goals,
objectives, and values. To this end, it becomes necessary to examine employees perception
of risk and organizational response to risk. Employees level of agreement to statements
about these organizational components reveals the extent to which they perceive their
organization as an HRO. This measures the degree to which employees share managements
goals and objectives. By studying organizational artifacts, to look for evidence of how high-
reliability practices are manifested, one can conclude whether or not a given organization can
be considered as being HRO-like. These research activities are designed to provide evidence
for applying the HRT theory to non-HROs.
Although HRO research came under intense criticism (e.g., Rijpma, 1997; Sagan,
1994, 2004), HRT theory revealed critical organizational-reliability characteristics that led to
organizational safety and reliability (Jeffcott, Pidgeon, Weyman, & Walls, 2006). As a result,
many organizations are finding it necessary to emulate business models that have a proven
track of working well in changing and challenging environments such as those organizations
are forced to confront today.
Significance of the Study
Since the establishment of HRT theory, only a few studies have examined the
concept of applying the theory beyond use in HROs (Barrett, 2008; Novak, 2006; Venette,
2003). While the former studies provided initial evidence supporting the concept, the scope
and limitations of these studies presented a challenge in generalizing the findings. This study
12


provides empirical evidence from across organizational and cultural contexts that strongly
support the concept of applying HRT theory beyond use in HROs. The study significance
resides in the fact that it will be the first to document both quantitative and qualitative
evidence, from two RSOs supporting the applicability and relevance concept, and the first to
provide such a broad evidence supporting HRO Perception Scale Instruments reliability
(Barrett, 2008, Venette, 2003) in examining employee perception about risk and
organizational response to risk. The two sub-scale instrument provides evidence that HRO
characteristics exist in an organization, and thus employees of an organization respond to and
perceive risk just like employees in the real high reliability organizations (HROs).
Researcher Bias and Stance
Several issues related to researcher bias and stance were acknowledged and
addressed throughout the data gathering and analyses phases. A description of these issues
and the steps that were taken to mitigate them follows.
My Role as an Employee
I have been a Dish Network employee for a little longer than twelve years. Before
Dish Network spun off EchoStar, I worked at EchoStar for two years. During these years, 1
assumed various managerial positions, the last of which is the Senior Program Manager of the
Dish Networks Corporate Initiatives Department. Thus, I developed biases and positions on
certain topics, especially biases that have to do with the distribution of power and roles.
Realizing these biases and acknowledging my potential subjectivity throughout the research
process helped me become more objective. I was concerned about the impact of my final
product on participants. I realized that at the end of my research process, I may be asked to
provide my results to evaluate and perhaps apply improvements within operations at Dish
13


Network and or EchoStar. I did not want anyone to be offended or marginalized by my
writing. So my goal and priority was to conduct this research as objectively as possible while
keeping any and all biases to a bare minimum.
Having worked in these organizations for so long obviously helped me gain access to
key people who assisted me in getting the necessary approvals for my research. Although
this wasnt immediate, the approval to conduct the research went back and forth several
times, as it would for any external researcher. The executive management of both
organizations granted me access to conduct the research when they were convinced no breach
of confidentiality for the organizations or employees would take place, and the work is going
to be free of bias and researcher stance.
Mitigating Bias in Data Collection
Most biases that normally result from in-depth interviews were eliminated by
gathering data in such a way that not only reduced researcher involvement, but also
guaranteed the quality and exclusiveness of the data collected in relations to the research
questions. This was done by (a) an online survey administered to all employees in Colorado,
(b) selecting to analyze organizational artifacts, and (c) using data from semi-structured pilot
interviews completed in 2009. Additionally, the research was not conducted during the
course of my work day, and the participants were not my direct reports. Using an online
survey kept the identity of the participants anonymous and enabled the researcher to reach a
larger group of participants that otherwise would be impossible through formal interviews.
The survey presented the questions uniformly and eliminated the possible effects of
researcher opinions being evident. This problem would more likely have occurred during a
structured interview, where visual or verbal indications can influence the survey respondent.
14


Mitigating Bias in Data Analysis
The analysis of online survey data, once collected, was direct and straightforward and
analyzed using SPSS and Excel tools. While the survey was distributed to departments and
employees who did not have any direct or indirect relations with the researcher, it may have
been learned by participants that the study was administered by a Senior Program Manager
from corporate headquarters. This could have led some participants to answer the questions
in one way or another. This may have been true in situations where the participant was not
happy with the leader or corporate headquarters for issues related to policy or administration.
To mitigate this risk and as part of the consent form participants had to sign, I made it clear to
all participants that (a) the research is not being done in the course of my employment, (b) the
results will not be shared with either organization unless they make a formal request in which
case only aggregate information will be shared, (c) the participants identity will not be
known, and (d) the results will have no negative or positive impact on the participants job or
performance.
In the case of analyzing the organizational artifacts and transcripts from the
interviews conducted as part of the pilot study, bias was dealt with more directly and
cautiously due to (a) my position as an employee of both organizations, (b) the perceptions,
opinions, and stance I may have developed in favor or against either organization or the
industry, (c) my experience as a technical Program Manager and a business professional with
advanced knowledge of organizational development and analysis, and (d) the natural bias any
researcher is subject to when conducting qualitative research.
Even so, with all that recognized and acknowledged throughout the project, my
compassion, interest, perceptions, values, and certain biases were still there and could not be
15


eliminated. However, total elimination of my bias was not as critical in this study because
the focus was on my ability to reduce bias to a bare minimum. To achieve that, I conducted
the pilot study interviews in such a way that enabled the participants true perceptions and
beliefs to come out freely. I reflected on the interviews alone and then shared the
transcriptions with each participant to ensure that my work reflected their voice and what
they intended to tell me. Even during the coding processes, the goal was to look for the
phrases and descriptions that provided a rich and thick description of participant answers.
When analyzing organizational artifacts, I managed the initial data coding from
information drawn from the literature on HROs. I predefined the labeling and categories
under which data were classified. Eliminating data was done when it was redundant or did
not relate to the research questions, and therefore would not have added any value to the
overall analysis. The interpretation and explanation of the results was straight forward and
was based on how the data was categorized and how the artifacts reflected the organizational
intent. To provide further triangulation and eliminate my influence in over-explaining the
manifestation of those artifacts, I went back and forth between the survey and interview data.
That provided more assurance that my perceptions and interpretations were aligned with
actual data and not any personal biases I held.
In summary, during the interviews, data collection, and analysis processes of
organizational artifacts, I was well aware and conscious of my biases. I took all measures
possible to ensure that I had no effect on the outcomes of the study. I took a reflective and
critical approach throughout the study to ensure that those biases were reduced to a bare
minimum. Despite all that, the explanations and interpretations in this study are mine, and
thus they are subject to the biases discussed above.
16


Study Limitations
There are several limitations to the present study. While some generalization can be
made to theory and practice, generalizing the studys outcomes to the entire population of
Dish Network and EchoStar cannot be made. What follows is a description of these
limitations.
HRO Perception Scale Instrument
In spite of the documented validity and reliability, the survey is fairly new and only
has ten questions. That could signal the questions are not sufficient or deep enough to
examine employee perception on such a complex topic. This is one reason why previous
research studies (Barrett et al., 2006; Venette, 2003) which only utilized surveys, combined
the survey with other behavioral surveys.
To deal with this weakness, the researcher worked with Dish Network and EchoStar
management and a group of five scholars, four of whom directed this research. The group
worked to modify the questions in such a way that fit the purpose of my study and the context
of the organizations. The researcher also randomized the questions on the actual survey to
ensure the participants are not led to answer the questions in one way or the other.
During the time the survey was administered, the researcher received several
inquiries from participants. Some did not feel a question was related to their work
environment; others couldnt understand what a question was asking. This could have
resulted in certain participants choosing not to complete the survey or to continue to
participate in the study. A total of 149 participants started the survey but did not complete it.
It could also have swayed participants to answer the questions in one way or the other, all of
which could have influenced the final results.
17


Sample Size
Both Dish Network and EchoStar have over 30,000 employees and departments and
employees scattered all over the world. The study targeted approximately 3,000 employees
in Colorado or about 10% of the total populations, so the perceptions reflected in the study,
while they represent a large group of diverse employees, do not reflect the perceptions of
every employee in both organizations.
The reasons for selecting the Colorado sites for this study are detailed in Chapter III.
However, the main reasons were (a) employees in other cultural settings respond differently,
(b) employees targeted represent the positions that are most likely to influence decision-
making policies and procedures and who also receive the most sophisticated training about
operational errors and high reliability standards and measures, and (c) Colorado houses the
corporate headquarters of both Dish Network and EchoStar, and so acts as a hub office for
other sites in which policy is made and culture is shaped.
Survey Response Rate
The response rate was 20% with 705 responses. This response rate, while being a
moderate response rate for an online survey, can be considered a fairly low response rate
when compared to total population in both organizations. The survey was administered
during a critical time for both companies as 19 Fox stations were taken down due to a dispute
between Dish Network/EchoStar and Fox Network. This was the first major dispute and
major channel takedown in the companys history. This event could have affected the level
of participation or the perceptions of those taking the survey. Finally, the researcher received
two email notifications from participants reporting the website hosting the survey was down;
a third notification reported the website took longer than anticipated to upload, and a fourth
18


notification reported the participants Proxy settings denied access to the website. These
issues could have negatively influenced the response rate.
During the survey administration, the researcher escalated the technical issues to the
proper stakeholder and got them resolved in a timely manner. This included getting in touch
with the websites technical help desk and the Dish Network and EchoStar IT Departments.
In order to increase the level of employee participation without directly influencing them, the
researcher sent two email reminders to all participants as provided for in the Human Subjects
Approval Process. The researcher also provided his contact information and was available to
answer any questions or concerns related to the study as was required by survey participants.
Organizational Artifacts
The review of organizational artifacts took place across both companies. This was
because the unit of analysis for this study was the entire organization and not the employees
of either organization or the employees from a given department. This resulted in best
practices/processes not being analyzed at each specific site or at the employee level. There
may have been key differences in practices and processes that were not captured in the study.
These could be playing a major role in how employees perform or perceive risk and
organizational response to risk. The literature explains that differences between employees in
different organizational settings and job classifications exist.
Research Methodology
Another limitation of this study could be the lack of study of the contexts of these
organizations. The study of context can be best done by in-depth interviews. Interviews are
by far the most beneficial, if not the best, approach to gather qualitative data because they
provide a narrative of current and historical events (Merriam, 1998). Also, interviews allow
19


for different perspectives from across the organization. To bridge the gap that resulted from
the absence of formal in-depth interviews, the researcher designed a mixed methodology case
study in which (a) organizational perceptions were collected via an online survey, (b)
organizational artifacts were gathered from around both organizations, and (c) the researcher
used input from two pilot interviews completed in preparation for this study in 2009. This
provided triangulation as well as rich and thick descriptions of organizational context through
those organizational artifacts. Future studies on this topic using direct observation, formal in-
depth interviewing through structured interviews, and using the employee as the unit of
analysis, will provide stronger conclusions.
Study Assumptions
The following is a list of assumptions upon which this study is based.
The study assumes Dish Network and EchoStar Communications are two RSOs.
Justification for this classification is in Chapter II.
The study assumes Dish Network and EchoStar Communications, while they are two
separate entities, are a single case study because they are managed by one CEO and
Chairman and are highly interdependent as Chapter II and III demonstrate.
The study assumes that the unit of analysis is the entire organization of Dish Network
and EchoStar Communications.
The study assumes that HROs do exist and are recognized as a form of organization.
The study assumes that HPOs do exist and are recognized as a form of organization.
The study assumes that RSOs exist but are not widely recognized as a form of
organization.
20


The study assumes the HRO Perception Scale Instrument validity and reliability have
been documented as reported in Chapter II (Barrett, 2008; Novak, 2006; Venette 2003).
The study assumes employees in different cultural settings may respond differently to
questions involving the examination of perception. This is largely the reason why
employees of Dish Network and EchoStar outside Colorado were excluded.
The study assumes that employee perception is the perception of interpreting our
surroundings or the reality we perceive from our systems (Johns, 1996).
The scope of this study does not include how organizations prepare and manage crises.
Operational Definitions
The following key terms and operational definitions are important to high-reliability
theory (Weick & Sutcliffe, 2001), the study of HROs, and to this study: High-reliability
theory (HRT), high-reliability organizations (HROs), high-performance organizations
(HPOs), reliability-seeking organizations (RSOs), and mainstream organizations (MOs) (see
Table 2). Unlike the literature on HPOs, the literature on HROs is rather new. So a fixed
definition for HROs is agreed upon by all HRO scholars and researchers. Thus, an HRO is
defined as an organization that regularly faces high levels of risks yet manages to conduct
relatively error- free operations over long periods of time and consistently makes good
decisions resulting in high and sustainable quality and reliability operations (Banerjee &
Mahoney, 2005; Bellamy et al., 2003; Bigley & Roberts, 2001; Busby, 2006; Evans, Cardiff
& Sheps, 2006; Gary, 2003; Kerfoot, 2007; La Porte, 1996; Popovich, Brizius, & Alliance for
Redesigning, 1998; Roberts & Rousseau, 1989; Rochlin, 1989, 1996; Roe & Schulman,
2008; Weick & Sutcliffe, 2001). No one defines HROs better than Weick and Sutcliffe
(2001).
21


Table 2
Related High Reliability Theory (HRT) and Organizational Types and Definitions
High Reliability Theory (HRT)
A theory developed from research conducted at high reliability organizations (HROs). It is
concerned with the successful management of the unexpected through continuous focus on
five mindfulness process. When those processes are at work in an organization, they enable
it to achieve high levels of reliability and able to manage and rebound from sudden changes,
planned or unplanned. The roots of the theory were developed by the work of Karlene
Roberts, Herbert Simon, James March, and Karl Weick. The most important early work in
HRT research was organizational sociologist Charles Perrows work on the Three Mile
Island nuclear incident in 1979 (Roberts, 1990; Roe & Schulman, 2008)
High Reliability Organizations (HROs)
Organizations that employ complex technologies, tightly-coupled and interdependent, and
operate in extremely high-risk environments where the threat of catastrophic failure is high.
They are organizations that operate with a high level of reliability because the prospect of
failure is high (Weick & Sutcliffe 2001)
High Performance Organizations (HPOs)
Organizations that have employees and leaders who are willing to be flexible, able to deploy
their talents to the organizations advantage, customer-focused, aware and attuned to the
needs of the organization and to changing marketplace conditions, and have a high degree of
accountability for their own actions. These organizations balance, realign, and renew their
market focus and position (through unique insights into the firms value), mastery of
distinctive capabilities (exploit a set of hard-to replicate capabilities), and anatomy (a
combination of distinctive capabilities that out-perform competitors) (Holbeche, 2005;
Kirby, 2005)
Reliability-Seeking Organizations (RSOs)
Organizations that are tightly coupled, operate in a complex rapidly changing environment,
and have no option or slack time to make errors. They are organizations that share the same
goals and objectives as HROs (Barrett et al., 2006; Vogus & Welboume, 2003)
Traditional (Mainstream) Organizations (MOs)
Traditional hierarchical organizations. They are organizations that have considerable levels
of political presence, manage by objective, and where power distribution and decision-
making processes are centralized. These are often seen as the father figure organizations.
(Avolio & Bass, 1999; Zand, 1972)
22


Imagine that its a busy day, and you shrink San Francisco airport to only one
short runway and one ramp and one gate. Make planes take off and land at
the same time, at half the present time interval, rock the runway from side to
side, and require that everyone who leaves in the morning returns the same
day. Make sure the equipment is so close to the envelope that its fragile.
Then turn off the radar to avoid detection, impose strict controls on the
radios, fuel the aircraft in place with their engines running, put an enemy in
the air, and scatter live bombs and rockets around. Now wet the whole thing
down with sea water and oil, and man it with twenty- year-olds, half of
whom have never seen an airplane close-up. Oh, and by the way, try not to
kill anyone, (p. 26)
Important and subsequent to the definition of HROs is the definition of mindfulness.
It is both a cognitive and communicative process that can occur across all levels of the
organization. Mindfulness is a combination of ongoing scrutiny of existing expectations,
continuous refinement and differentiation of expectations based on newer experience,
willingness and capability to invent new expectations that make sense of unprecedented
events (Weick & Sutcliffe, 2001, p. 42).
Krieger (2005) and Langer and Moldovenanu (2000) define mindfulness as a
psychological state in which individuals actively participate in information processing while
doing their normal jobs. It is a comparative analysis in which employees constantly analyze
and categorize data. The power of mindfulness resides in its ability to reinvent employees.
This happens when employees reexamine discarded information, or monitor how categories
affect expectations or remove dated distinctions. This means that employees of an HRO
exploit two key points (Weick & Sutcliffe, 2001): (a) expectations and, (b) categories. By
doing so, they constantly rework, refine, update, and replace what needs replacement, and
thereby catch unexpected events in the development phase and halt them. This is the soul of
mindfulness and this is what MOs do not prioritize because they are preoccupied with
success; by focusing on their goals and objectives but not the unexpected.
23


Summary
Many mainstream organizations (MOs) are not learning from their failure, or other
organizations failure and collapse. Despite many threats and challenges in their
environment, high reliability organizations (HROs) that manifest the HRT principles have
been a role model for many organizations in the mainstream (MOs), because they continue to
operate with high reliability. Using mixed methodology research, this study explores the idea
of advancing HRT theory to RSOs and MOs by surveying Dish Network and EchoStar
employees perceptions and validating those perceptions with evidence of HRT practices
gathered from the study of organizational artifacts and interviews. The study utilizes an
HRO Perception Scale Instrument to measure the perception of members of reliability-
seeking organizations (RSOs) toward risk and organizational response to risk in order to
determine whether or not employees: (a) perceive their organization as high reliability
organization (HRO) and (b) share the same perception of reliability and purpose of the
organization as top management, employees of HROs, and employees of other RSOs in
previous studies. The study of the organizational artifacts and interviews provide in-depth
analysis of how the HRT principles are manifested in the organizations in this study, Dish
Network and EchoStar Communications.
24


CHAPTER II
LITERATURE REVIEW
Organizations
An organization can be defined as a social entity, within our larger society, that was
developed to attain clear goals and objectives and consists of internal components that have
been carefully planned to achieve maximum capacity (Bedeian & Zammuto, 1991).
Organizations have three key characteristics: organizational designs, organizational
structures, and organizational strategies. Organizational design is defined as the pattern of
coordination and control, workflows, authority, and communication that guides the
interactions of different members for the purpose of getting the work done, while
organizational structure is defined as linking departments and jobs (Bedeian & Zammuto,
1991). In contrast, organizational strategy is defined as the pattern of actions and decisions
organizational leaders make to achieve and exceed the declared goals and objectives (Bedeian
& Zammuto, 1991).
There are several reasons why mankind has been interested in studying
organizational design and figuring out what works best (Bedeian & Zammuto, 1991): (a)
organizations have become an instrumental means through which mankind is able to harness,
control, and shape the world today; (b) organizations have become powerful social and
financial forces in our societies; (c) studying organizations holds great value considering they
are places of employment, employing most of our workforce; (d) being such powerful social
and financial forces, organizations have become an agent for economic and social change;
25


and (e) organizations are at the center of our political system with most organizations having
connections to one or more policymakers.
The worlds increasing complexity and the rapid and changing growth in demand, as
well as the fast turnaround times on technological cycles, have all caused many unprepared
organizations to fail (Weick & Sutcliffe, 2001). Such environments are no longer forgiving
of operational slackness or mindlessness (Bigley & Roberts, 2001). This is due to the nature
of organizations as open complex systems affected by many factors within and outside their
environments. The next section discusses the nature of organizations as complex systems.
Organizations as Complex Open Systems
Organizations are no longer self-contained or closed, and thus the bureaucratic
system introduced by Weber in the first half of the twentieth century is no longer reliable
(Anand & Daft, 2007; Bigley & Roberts, 2001). Thus, many managers and leaders are
constantly preoccupied with the questions: What organizational structure is a better fit? How
do I design my organization in a way that will ensure that it remains flexible, learning, and
mindful? The answer to these questions was sought for many years, and research in
organizational theory provided many forms of organizational design and theories that can be
used to structure organizations and drive performance.
Studying organizations as complex open systems was dealt with more formally by
Thompson (1967). He developed two approaches for studying working-organizations: (a)
closed-systems strategy and (b) open-systems strategy. In closed-systems, the organization
applies its resources in a functional manner to achieve efficiency and reduce uncertainty. In
comparison, the open-systems strategy states that no one can ever account for all the known
and unknown variables that influence organizations. Thus, we should expect surprise and
26


uncertainty. As HRO literature will demonstrate, this notion is aligned with the NAT
conception that accidents are normal but not apart from the main conception of the HRT
theory. It actually forms the basis for why the HRT theory is applicable to organizations of
all types. The HRT theory is about managing the unexpected and halting it from developing
into a catastrophe.
Thompson (1967) identifies two elements to structuring organizations: (a) the
stability of the environment or how fast it changes and (b) heterogeneity or the number of
entities the organization is required to deal with. Thus, he proposes organizations can reduce
uncertainty by breaking their design into subdivisions which should provide better stability
and homogeneity. He also suggests they create separate organizational units to deal with
individual subdivisions. Thompson discusses organizational complexity in terms of being an
open or a closed system. He explains there is a conflict between open and closed systems in
that they are not comprehensive. He states the closed system does not accommodate
environmental differences while the open system over explains the issue of organizational
adaptability. However, he makes the case that organizations should be managed from both a
closed and an open system perspective. He recognizes organizations as complex systems,
with interdependent components, that need to adapt to their environment and conceptualizes
that because uncertainties will arise from the environment or advances in technology,
organizations develop their own way of responding to those risks and changes. Their
response creates differences in the different organizational levels in order to deal with
uncertainty. This interaction with the environment and the influence from internal
interdependencies, demands the flexibility to adapt. He states that each organizations inputs
27


and outputs will be determined based on its context, and thus will likely differ from other
organizations. This creates a need for organizational design and structure.
Thompson (1967) affirms that the challenge facing all organizations is their ability to
manage and cope with uncertainty. He explains uncertainty arises from two external and one
internal influences (a) lack of cause and effect understanding of the culture, (b) contingency
in which the environment plays a key role in determining the organizational outcome, and (c)
interdependence of components (internal). This is how he ties together the incompatibility of
the open and closed management approach to organizations as systems and how he explains
the behavior of complex organizations.
Thompsons (1967) theory of interdependence is exceptionally important to todays
organizations. The three types of interdependence (pooled, sequential, and reciprocated)
could be used to characterize whole organizations. Interdependence between organizational
components and employees creates a shared awareness that is an essential component to
resilience. An organization, to be effective, needs to be made up of units and divisions that
are flexible to adjust for coordination as uncertainties arise. The alternative is being unable to
rebound from shock, and thus poor organizational reliability and then performance.
In summary, there is no question that the ways in which organizations are designed or
restructured directly impact their ability to respond to a crisis, perform, provide reliable
products and services, and sustain or improve profitability (Anand & Daft, 2007; Bedeian &
Zammuto, 1991; Lin et al., 2006). Also, there is no guarantee that HPOs will continue to
perform when they are struck by the unexpected (Perrow, 1984). Because of this, so many
organizational designssuch as self-containing organizations in the 1800s, and then
functional, divisional, horizontal, hollow, modular, and virtual organizations in the 1900s
28


have come along. While there are many different design models, no single design fits all (Lin
et al., 2006); not a single organizational design was suggested as a better fit in all situations
(Carley & Lin, 1997; Lin et al., 2006).
Four Organizational Designs
The present research is focused on the four types of organizational models most
relevant to the studys purpose and objectives. Following are definitions of those
organizational models mentioned throughout this document by name or abbreviation.
Mainstream organizations (MOs). MOs are traditional hierarchical organizations
that have considerable levels of political presence. They typically use management by
objectives and centralize power distribution and decision-making processes (Avolio & Bass,
1999; Zand, 1972).
High performance organizations (HPOs). HPOs have employees and leaders who
are willing to be flexible, are able to deploy their talents to the organizations advantage, and
are customer-focused, aware and attuned to the needs of the organization, and to changing
marketplace conditions. These organizations have a high degree of accountability for their
own actions. They also balance, realign, and renew their market focus and position (through
unique insights into the firms value), mastery of distinctive capabilities (exploit a set of hard-
to replicate capabilities), and anatomy (a combination of distinctive capabilities that out-
perform competitors) (Holbeche, 2005; Kirby, 2005).
Reliability-seeking organizations (RSOs). RSOs operate in a dynamic and
changing environment, are tightly-coupled and interdependent, and place a special focus on
employing the HRO mindfulness processes to achieve and sustain high-levels of reliability in
order to succeed (Vogus & Welboume, 2003).
29


High reliability organizations (HROs). HROs employ complex technologies, are
tightly-coupled and interdependent, and operate in extremely high-risk environments where
the threat of catastrophic failure is high. As a result, because the prospect of failure is high,
they need to operate with a high level of reliability (Weick & Sutcliffe, 2001).
Organizational Performance Background
Many obstacles stand as roadblocks to applying any high performance practices in
organizational settings. First, how do we go about determining among so many successful
organizations which ones are real HPOs, or among so many organizational theories which
model can be repeated in different organizational contexts? Second, should the assessment be
time bound, and if so how far back should we go? Last, what measures should we use to
measure the performance of such organizations?
The previous questions have been researched for decades; no easy answers have been
found. Managers and business owners have always looked for ways to improve their
organizational performance. This search dates as far back as the industrial revolution when
factory owners were aggressively attempting to change workers mindset from agrarian to
factory. Three characteristics of the industrial revolution changed our way of life: (a)
development of machinery, (b) linking human power to machines, and (c) establishment of
factories able to employ a large number of workers (Cascio, 1995). As a result of this
continued research, scientific theories about how to improve worker productivity intensified.
The main focus of this body of research was how to design and structure a form of
organization that produced maximum efficiency.
Following the industrial revolution, the human relations movement began and studies
indicated the level of productivity was a direct result of teamwork and cooperation. So the
30


organization, for the first time, was now being viewed as a social context (Cascio, 1995).
Primarily, the classical view of management asserted that the keys to worker efficiency and
organizational productivity were (a) efficient job design, (b) use of appropriate incentives,
and (c) effective managerial functioning (Montana & Chamov, 1987). It would be
generalized later that in order to increase productivity, managers need to develop a better
understanding of workers needs and social contexts. This generalization was supported in
intensive research in organizational theory. Brown and Duguid (1991) affirm social context
of people doing the same jobs play a key role in determining an organizations ability to
create high quality products and services. Workers who are in the same war-room, working
closely with one another, and reading the same manuals are more likely to interpret ideas
similarly. Toulmin (2001) emphasizes that employees need for stability and predictability
leads to increasing their sense of purpose and commitment to the organization, which
eventually leads to self-preservation of organizations.
The search for key performance factors in organizations, and the ways to improve the
organization of workers, continues and is always challenged and shaped by changes and
demands in our society. During the 1980s, many American organizations discovered that
mass production systems created during the industrial revolution are no longer fit to meet
todays production challenges and market demands (Popovich et al., 1998). In order to
achieve long-term success, organizations concluded that they needed to establish and deploy
a reform that would transform corporate cultures, budget, human resources, and procurement
systems (Sutcliff & Donnellan, 2006). So the search to discover the keys for high
performance continued and theorists kept building on one anothers theories. Tables 3a and
3b provide a historical overview of literature on organizational performance
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Table 3 a
History of Research on Organizational Performance Literature by Author 1982-1995
1982 1984 1992 1994 1995
Book In Search of Excellence Normal Accidents Corporate Culture Built to Last Boundary-less Organizations
Author Peters & Waterman Perrow Kotter & Heskett Collins & Porras Ashkeans
Unit of measurement in the analysis Compound asset and equity growth, market value to their book value, return on capital, equity, and sales Incident and accident report Net income, average returns on invested capital, and appreciation in their stock price Core values; profitability Organizational boundaries; boundary-less
Table 3b
History of Research on Organizational Performance Literature by Author 2000-2005
2000 2001 2001 2001 2005
Book Peak Performance Creative Destruction Profit from the Core Managing the Unexpected Accenture- published materials
Author Katznbach Foster & Kaplan Zook & Allen Weick & Sutcliff Kirby
Unit of measurement in the analysis Market superiority over several years Market superiority over several years Shareholder total returns Remained failure free Market superiority over several years
32


including defined key performance drivers that contributed to organizational effectiveness
over time. This literature formed the basis for the HPO theory in HPOs and HRT theory in
HROs based on which this study was based.
The literature review that follows is organized around two key organizational
designs: HPOs and HROs that promise to bring about positive organizational change, high
performance, and long-term reliability and survivability.
Literature Review on HPOs
HPO companies are the role model for other MOs (Holbeche, 2005). They represent
a metaphor for how a new version of organizations can be aligned and managed successfully
(Sutcliff & Donnellan, 2006). They are unique because they are employee-, processes-,
technologies-, and techniques-centered, and may or may not encompass the entire
organization or organizational units. In addition, HPOs are flexible and not restricted to
traditional boundaries (can include other bureaus, agencies, and may create links across other
entities both private and government). They are able to make the greatest contribution to
achieve their mission and provide the highest quality products and services, and produce
results using the same or fewer resources than other organizations.
As an organizational solution to employee performance and competitive pressure,
HPO work practice initially attracted attention, mainly in the manufacturing sector
(Kalleberg, Marsden, Reynolds, & Knoke, 2006). Table 4 provides a comparison of how
different these HPO practices are from the more traditional ones (Popovich et al., 1998).
MOs interest in the HPO model stems from the desire to apply the lessons learned in
those organizations to improve their own bottom-line and rebound from failure (Sutcliff &
Donnellan, 2006). Langabeer (2008) explains that organizations have three
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Table 4
Comparison of Traditional MOs and HPOs
Design Elements MOs HPOs
People Narrow expertise Multitasked
Rugged individuals Team player
Decision Systems Centralized Decentralization
Closed Open
Human Resources Standardized selection Realistic job interviews
Systems Routine training Continuous training Performance-based pay
Job-based pay Enriched jobs
Narrow, repetitive jobs Self-regulating teams
Structure Tall, rigid hierarchies Functional departments Flat, flexible hierarchies Self-contained businesses
Values and Culture Promote compartments Routine behaviors Promote involvement, innovation, and cooperation
strategic paths when performance is disintegrating: (a) closure, (b) acquisition or merger, and
(c) turnaround or rebound. He suggests successful organizations rebound when they focus on
(a) streamlining certain programs, (b) eliminating unprofitable lines of business, and (c)
partnering with the competition or other strategic alliances.
The American Management Association (2007) concluded that HPOs are superior to
their low performing counterparts in the following areas:
HPOs strategies are consistent, clear, and well thought out.
HPOs are more likely to provide exceptional customer service.
34


HPOs are more likely to adhere to their ethical code of conduct in all business units.
HPOs leadership is clear, fair, and talent-oriented.
HPOs are clear and concise when it comes to their performance measures, training,
and human relations.
HPOs workforce is more likely to view the job as a long-term career.
HPOs workforce is more likely to use their skills, knowledge, abilities, and
experience to provide top quality products and services.
Defining HPOs
Many years have passed since researchers first attempted to define HPOs, yet, we
still do not have a clear definition (Kirby, 2005). However, the HPOs literature reveals many
working definitions. The first of these is Popvichs (1998), who defines HPOs as a group of
employees who produce desired goods or services at higher quality with the same or fewer
resources. Their productivity and quality improves continuously, from day to day, week to
week, and year to year, leading to the achievement of their mission (Popovich et al., 1998).
Holbeche (2005) defines HPOs as organizations that have employees who are willing to be
flexible and able to deploy their talents to the organizations advantage. Pasmore (1994)
supports Holbeches notion and explains the only way organizations can survive is to be
flexible. He explains that HPOs see change as an opportunity and separate themselves from
their floundering counterparts. The secret is that this attitude toward change improved their
willingness to accept changes gracefully and respond flexibly, and not simply with more of
the same.
Another definition of HPOs is offered by Sutcliff and Donnellan (2006). They
describe them as businesses that continually balance, realign, and renew their market focus
35


and position (through unique insights into the firms value), and master distinctive
capabilities (exploit a set of hard-to replicate capabilities) and anatomy (a combination of
distinctive capabilities that out-perform competitors). Other researchers (Hesselbein &
Johnston, 2002; Thompson & Heron, 2005) define HPOs as organizations that aim to deliver
consistency, quality, and responsiveness. Still others (Castel & Estes, 1995) define high-
performance learning communities as pragmatic, flexible tools that focus on curriculum,
assessment, staff development, and health and social needs. They explain these are natural
outcomes of a HPO that adopts a systemic approach to change. There is no common
definition.
Mohrman and Wohlstetter (1994) apply the HPO concept to educational
organizations when they define high performance schools as schools that continually improve
their performance and efficiency year after year. They are organizations where power,
knowledge, information, and rewards are decentralized, thereby creating a unique culture that
fosters student and faculty learning. Such an organizational culture is then centered on the
belief that students can achieve. Bradford and Cohen (1997) define HPOs as organizations
that employ high-performance employees whose goal it is to produce high-quality solutions,
provide coordination among team members, have a shared responsibility, and consistently
achieve a level of departmental performance far beyond a single leaders capability.
Similarly, Intagliata, Ulrich, & Smallwood (2000) define high-energy HPOs as those
characterized by leadership that pursues continuous learning and process improvement.
Finally, Blanchard (2007) offers the definition that HPOs are enterprises that produce
outstanding results with the highest customer satisfaction.
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In summary, HPO literature is rich with more scholarly work that defines these
HPOs characteristics. Alternatively, Appendix B summarizes yet a different approach to
becoming a HPO. The model is called the SCORES model by Blanchard (2007). Building
on all these different definitions and the literature that explains the attributes of HPOs, Table
5 provides a summary of key performance drivers by attribute that helped HPOs achieve their
stated goals and objectives.
Characteristics of HPOs
MOs normally measure success by using factors such as market share, sales
revenues, quality, innovation, return on investment (ROI), and employee flexibility (Ahmed,
Montagno, and Firenze, 1995). These became the standard characteristics of many MOs.
However, Nohria, Joyce, and Roberson (2003) explain being big is not a guarantee that high
performance products and services will be delivered. They affirm even low-cost should not
dominate the thinking of organizations. Instead, organizations should be focused on
delivering what they have promised customers. Sutcliff and Donnellan (2006) support this
assertion and report that of the 172 largest companies on Fortunes 1955-1995 list of the 50
largest organizations, only 5% sustained 6% growth throughout their time on the magazines
list for the period. Thus, scale alone doesnt assure long-term success. Nohria et al. (2003)
explain that organizations need to balance and outperform in four core areas: strategy,
execution, culture, and structure. They also need to do that in two of four additional areas:
Talent, leadership, innovation, and mergers and partnerships. The HPO literature confirms
these are areas in which HPOs have excelled.
In their report on how to build a HPO, the American Management Association (2007)
presented a model with five characteristics of HPOs. Appendix C details those
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Table 5
Key Performance Drivers in HPOs by Attribute by Literature References
Attribute Key Performance Drivers Literature References
Strategy Customer-centric Market-focus Clear vision, mission, and values Focus on business core and core values Create collective mindfulness Ashkeans, 1995; Collins & Porras, 1994; Foster & Kaplan, 2001; Katznbach, 2000; Kirby, 2005; Kotter & Heskett, 1992; Peters & waterman 1982; Weick & Sutcliffe, 2001; Zook & Allen, 2001
Management Promote individual achievement Recognize and celebrate success Value-driven management Katznbach, 2000; Peters & Waterman 1982
Structure Loose-tight structure System and people flexibility Process redundancy Strategy alignment with goals and objectives Renewed management Ashkeans, 1995; Perrow, 1984; Peters & waterman 1982; Weick & Sutcliffe, 2001
Opportunity Invest in new businesses New decision-making system Constantly learn and unlearn Uncover hidden assets Ashkeans, 1995; Foster & Kaplan, 2001; Kirby, 2005; Zook & Allen, 2001
characteristics and compares them to HPO literature to provide yet another HPO model from
a different organizational context. Table 6 provides a summary of the
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Table 6
Summary of HPO Characteristics in the Literature
Characteristics of HPOs Literature References
Promote growth by focusing on the business core Blanchard, 2007;
and the expansion of alliances Ellsworth, 2002;
Clarity of purpose (vision, mission, and values) Kirby, 2005;
Committed employees with high morale Holbeche, 2005;
Balance strategy, execution, culture, and structure Nohria, & Roberson, 2003;
Sutcliff & Donnellan, 2006;
Balance, align, and renew market focus and position Zook & Allen, 2001
Knowledge sharing is readily available
Open communication channels
Systems, structures, processes, and practices are aligned
Power and decision-making are distributed
Promote anatomy, participation, collaboration, and teamwork
characteristics of HPOs as described in the literature by reference. These characteristics
represent whats known in the literature about HPOs.
Leadership and Culture in HPOs
HPO literature explains that sustaining the conditions that foster an organizations
HPO status requires a strong culture in which employees are engaged and leadership plays an
important role. Employee engagement involves the creation of a shared sense of destiny and
belonging. Holbeche (2005) suggests employees experience such engagement when they (a)
feel involved; (b) are aware of the organizations vision, mission, and statement of values and
believe in them; (c) feel their management is credible; (d) see how their work affects the
39


bottom-line; and (e) feel respected, trusted, and a sense of belonging. Leaders in turn need to
engage people to do willingly and well what needs to be accomplished. Popovich et al.
(1998) emphasize that corporate sustainability is linked to global issues, human relations,
corporate citizenship, and community involvement. They present eight principles culturally
nested that define the culture characteristics of HPOs. Appendix D provides a summary of
these characteristics.
HPOs are characterized by having strong well-established cultures that guide the
behavior of employees and management to achieve high performance levels. The importance
of leadership for HPOs stems from the need and ability to create the social architecture of the
organization (Holbeche, 2005). To do so, leaders need to create an environment that employs
and encourages the ideas and implementation of innovation, knowledge sharing, learning,
development, and high performance, all of which are important elements in building HPOs.
Holbeche (2005) argues that in order for the organization to remain successful it must (a)
think long-term as it acts in the short-term, (b) collaborate and compete at the same time, (c)
be customer-centric, (d) adopt fast product turnaround cycles, (e) create consistent vision and
effective leadership, and (f) always put employees first. Getting there will require
that the organization and its stakeholders (a) develop change-ability strategy, (b) build
positive psychological bindings with stakeholders, (c) organizational commitment to
stakeholders (safety, security, rewards, affiliation, and growth), and (d) stakeholder
engagement.
Organizational literature on leadership and power documents the importance of
leadership and distribution of power in organizations and how they shape an organizations
culture. Holbeche, (2005) explains that a bonding with employees can be established by
40


leaders and leadership strategies that focus on influence rather than coercion. Muth (1984)
reports that the greater the coercion the greater the conflict, and thus the less the
effectiveness. In contrast, Muth also proposed that the greater the influence, the greater the
consensus, and therefore the greater the effectiveness. Blanchard (2007) explains that
leadership in HPOs is important because it represents the engine that allows the organization
to get to its destination. Leadership in HPOs is not centralized. It is found in every level and
layer of the organization. HPOs prepare subject matter experts in every comer of the
organization so that a leader emerges anytime and every time a decision is required. Other
researchers (Dunphy, Girffiths, and Ben, 2007; Holbeche, 2005) emphasize that leaders in
HPOs have a key role to play especially in building organizational culture.
Transitioning to HPO Status
Moving to high performance is not a linear process and it takes time. The process
could take years but must be accelerated through incentives and other built-in motivators
(Popovich et al., 1998). HPO literature explains the process could start in specialized
departments within the organization before a total makeover is introduced to the rest of the
organization, so an organization can have a high-performing department and a low-
performing one. However in order for an organization to totally rebound and become a HPO,
successful strategies must involve multiple departments and key positions (Langabeer, 2008).
The following is a summary of the HPO literature on how MOs can move to HPO status. It
should be noted that just as there are many HPO definitions, there are many ways to move
into high-performance status.
Popovich et al. (1998) suggest four steps that can make the process go smoother and
easier when preparing to move an organization into high-performance status.
41


]. Prepare the way to change by clarifying the purpose, understanding the
environment, engaging stakeholders, and earning stakeholder commitment.
2. Be clear and concise when crafting the vision, mission, and values.
3. Conduct useful organizational assessments that serve three purposes (a)
championing and motivating stakeholders for change, (b) identifying opportunities, and (c)
monitoring progress. Assessing the need for change can be accomplished by focusing on best
practices, benchmarking, quality assurance, and components of organizational design.
4. Design a results-driven plan for change that includes (a) translating the vision
statement into something measurable, dated, relevant, and achievable; (b) aligning policies
and procedures with the organizations strategy; and (c) evaluating change strategies to gain
experience.
In their study of hundreds of leading organizations worldwide across multiple
industry sectors, the Accenture Institute for High Performance Business found that the
dynamics of certain industries encourage the creation of long-term value (Sutcliff &
Donnellan, 2006). They suggest organizations are able to optimize market focus and
position, and thus become HPOs when they have learned three vital strategic questions.
1. How to manage for today and tomorrow. HPOs are mindful of today and
tomorrow.
2. How to best parent operated businesses. HPOs are known to choose highly value-
added activities.
3. How to compare through organization design. HPOs, unlike MOs, know that their
strength is in the way they execute their strategies and business plans.
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Some researchers (Harvard Business School, 2002) explain that when it comes to
high performance, traditional management approaches have come up with partial answers as
to how high performance is achieved (rewards, right culture, and management by objective).
They explain the current focus to high performance is on the relationship between emotional
intelligence and high performance. A successful approach to sustained high performance is
pulling together employees spiritual values. The belief is that deeper values (the body, the
emotions, the mind, and spirit) influence performance.
Lawler (1996) argues that moving toward high performance is a necessity and
requires high levels of total quality management (TQM) in four areas: (a) quality, (b) cost, (c)
speed, and (d) innovation and development. He further explains that HPOs are those where
employees understand the organizations objective, strategy, performance status, customers,
and competitors. Also, employees of a HPO are rewarded according to the success of the
organization, and they are treated as part owners. Finally, employees work in teams and are
able to influence important organizational decisions such as work methods and strategy
decisions. Holbeche (2005) adds that building culture, a primary component of HPOs, takes
time and more likely will involve changes of all types. She explains moving to high
performance requires an organization to be flexible, with a supporting information
technology systems, an organizational culture that assures employees and the management
behaviors are in line with the organizations strategy, and stakeholders willingness to
change. Drawing on research conducted on HPOs such as Barclays, Cisco, Dow Chemical,
3M, and Roche, researchers Mankins and Steele (2005) reveal while on average companies
deliver only 63% of what they are expected to deliver. High performance can be achieved by
the following strategy points: (a) keep it simple, make it concrete, and have clear goals and
43


objectives; (b) debate assumptions, not forecasts, and create cross-functional teams who can
help align the strategy of the organization with its goals and objectives; (c) use a rigorous
analytic framework and establish a framework between the corporate center and the business
units to ensure a rigorous discussion of market trends; (d) clearly identify priorities;
employees need to know where to direct their efforts, (e) continuously monitor performance
by using feedback to assess cost vs. benefits; and (f) reward and develop execution
capabilities in both employee motivation and development.
Bradford and Cohen (1997) identify seven critical components in building a high-
performance department: (a) the most important factor in assessing the appropriateness and
need for change rests in the hands of the leader; (b) while conditioning the turf for change,
not all conditions have to be perfect before the change is made; (c) sending initial signals to
subordinates through clear communications, no matter the message; (d) building mutual-
influence relationships with difficult subordinates by working one-on-one with employees;
(e) developing a shared-responsibility team to increases the sense of belonging and improve
team cohesiveness; (f) developing individual subordinates because training and development
are worth the investment and will eventually help the organization reap the benefits; and (g)
identifying and gaining commitment to overarching goal by building a common point of view
from a variety of different perspectives.
Other researchers (Castle & Estes, 1995) suggest six characteristics that lead to
building high-performance teamsthe engine of any HPO: (a) they have a shared vision, (b)
they use a leading-edge technology, (c) the leader is most influential, (d) they have a variety
of learning settings, (e) they are structured to provide a safe and supportive environment, and
(f) they have a cohesive-management strategy.
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Sustaining High Performance in the Long-Term
The literature on HPOs provides different avenues for how an organization that
achieved a HPO status can maintain and improve that status. Sutcliff & Donnellans (2006)
research into HPOs revealed five common leadership and productivity-enhancing
characteristics that can help sustain high performance over time.
1. Leadership: Direct leadership involvement and sponsorship of programs, quality,
and change agendas is required to sustain high performance. In support of this finding,
Holbeche (2005) explains leaders at all levels of the organization play a major role in creating
adaptability to ongoing change. She states that managers in HPOs manage the ideas and not
the functional boundaries. She further explains leaders of an HPO must be able to market
their vision and organization to all stakeholders.
2. Value-Focused Structure: The structure of the organization needs not be a
roadblock to value creation. Bradford and Cohen (1997) explain that the systems within an
organization need to support innovation at all levels. For example, decision-making needs to
be more dispersed. Similarly, Boleman and Deal (1997) explain that the organizations
structure is important because it is basically the blueprint for expectations and exchanges
among the different stakeholders.
3. Skills and Capabilities/Talents: The organization needs to have the necessary
training and education in place to drive performance. Castle and Estes (1995) explain that
job performance variations are the result of the ways in which employees execute their work.
Harvard Business School (2006) explains that for an organization to achieve efficiency and
effectiveness the supply of resources for each job should equal to the demand. Holbeche
(2005) reports that as jobs change, skill requirements alter. She found that organizations that
45


maintain investment in training and development will reap the benefits of employee
commitment and up-skilling.
4. Value Mindset and Culture: Employees need to be able to feel and see how their
action affects the organization. Collins and Porras (1994) found each of the eighteen
organizations they studied had dynamic, change-oriented climates where employees felt a
sense of responsibility and belonging. Holbeche (2005) found that when employees are
empowered and have the skills they need, they are likely to be responsible and accountable
both of which increase their sense of belonging and self-esteem. She adds that talented
employees want to be involved, equipped to do their job and get rewarded. They want career
ladders, the ability to balance home and work life, flexibility, and opportunities to develop
their skills and continue to learn.
5. Aligned Incentives and Rewards: An incentive plan will link total returns to
shareholders directly and then future performance. According to Holbeche (2005), HPOs are
all about people. What the organization does to motivate, energize, retain, develop, train,
educate, and improve the sense of belonging for and between employees is critical to the
achievement and sustainability of high performance. In support of this, Ellsworth (2002)
suggests that customer-centric organizations (a) find it easier to implement or adapt to
change, (b) have employees who find their work purposeful, (c) have a higher return on
investment, (d) have a stronger and supportive culture, and (e) have strategies more aligned
with their goals and objectives.
Boleman and Deal (1991) suggest that achieving and sustaining high-performance
results is possible when the organization benefits from a motivated and talented workforce.
They offer a framework and a list of strategies for organizations to build such a workforce:
46


(a) develop and implement a clear organizational philosophy, (b) hire the right employees, (c)
retain employees, (d) reward employees, (e) protect jobs, (f) promote from within, (g) share
the wealth, (h) invest in employee training and development, and (i) empower employees.
Similarly, Popovich et al. (1998) present a set of requirements for sustaining HPOs: (a)
sustained leadership, (b) established performance measurements, (c) high-quality products
and services at a low cost, and (d) resource allocation to support continuous organizational
learning.
Summary of HPO Shortcomings
Sutcliff and Donnellan (2006) explain that the fundamentals of high performance
changed three times in the last decade. This reflects the dynamics of our environment, the
scope of challenges businesses are facing, and rising and changing customer demands. The
HPO literature review shows how focused HPOs are on meeting a fixed set of predefined
goals and objectives. According to Weick and Sutcliffe (2001), an organizations
preoccupation with successto the extent its focus is on confirming expectationswill
divert all its efforts and attention to the aspects of that expectation. This results in that
organization seeing less, not more. As a result, the big picture is lost and the organization
finds its way to failure. This happens primarily because organizations focused on achieving
short-term success turn organizational efforts towards short-term gains and efficiency as
opposed to long-term success through reliability and safety. The organizations management
and staff become more concerned about their individual achievements, reduce work forces to
cut costs, and execute other actions to validate the expectations set forth. These efforts go in
the opposite direction of HPO fundamentals. The consequence is that in making the balance
sheet and stock price look better quality suffers. This mindset takes away the organizations
47


ability to be mindful, and creates an inability to manage changes in the market, consumer
demands, or crises when they strike turning an organizations agenda into a recipe for
disaster, rather than a plan for success. Smart et al. (2003) suggest that recent tragedies have
shown to be threatening to the short-term sustainability of organizations designed on the basis
of short-term efficiency gain. Further, by doing so, organizations left no slack time to be able
to respond to sudden changes in their environment. The result is that organizations do not
have the means or sufficient time to contend with complex and dynamic environments. Thus,
new HPO performance fundamentals become necessary, and this explains why the basic HPO
fundamentals keep changing with time.
HPO Theory at the Crossroad
While there appear to be many HPO definitions, many fundamentals for high
performance, and many high-performance characteristics and attributes, HPO theory does not
constitute a repeatable model. It also does not guarantee long-term success in those where
the model can be applied. The literature explains there are HPO fundamentals in bits and
pieces form. However, binding these together throughout the organization and making them
consistent from top to bottom requires more than those fundamentals.
Because of societal and cultural changes post 9/11 and constant changes in the
context of organizations, the focus on reliability as a mean to manage for long-term success is
increasing (Weick & Sutcliffe, 2001). HPO literature shows that to achieve their goals and
objectives, HPOs find themselves cutting costs and/or staff, downsizing, merging or reducing
resources (Holbeche, 2005; Sutcliff & Donnellan 2006), which render them as low- reliability
organizations, and subject them to failure, or threaten their existence entirely (Roberts, 1990).
Baneijee (2005), commenting on the Columbia Accident Investigation Board, reported the
48


following as some of the many reasons leading to the Columbia disaster in 2003: (a)
technological uncertainty, (b) a can do culture that overlooked safety threats, (c) schedule
pressures, (d) budget constraints, (e) downsizing, (f) financial uncertainty, (g) and political
uncertainty. This conclusion is supported by Smart et al. (2003), who suggest that recent
tragedies showed how vulnerable organizations, designed on short-term efficiency, are to
failure, even though they may be considered HPOs.
The reasons listed above may explain why many organizations once considered
HPOs, such as Enron and WorldCom, no longer exist. To this point, some researchers
(Holbeche, 2005; Popovich et al., 1998) argue that todays business environment is volatile,
competitive, and demands a new business model, one that is built around flexibility and
resilience (i.e., HROs). Lin et al. (2006) claim that not all organizational designs are best
suited to manage for long-term success and that an organization built on flexibility is better
than an organization that attempts to restructure after or during a crisis. They acknowledge
failure is a part of the process and thus cannot be ruled out. To this end, Weick and Roberts
(1993) argue that the traditional managerial practices we are accustomed to are designed to
protect organizations from potentially disruptive events, while HRO practices are designed to
manage that and the unexpected. They do it by constantly being mindful of any errors or
changes in the organizational environment, and making the necessary adjustments to
guarantee continued reliability of operations, products, and services. Managing latent errors
is key to sustained reliability and to managing the unexpected in HROs.
The search for a theory that provides answers to achieving and sustaining high-
performance status over time is moving beyond the HPO phenomenon. Smart et al. (2003)
suggest the answer to long-term success comes from research on HROs that privilege
49


integrity in the achievement of medium-and long-term efficiency gains. HPO as a theory
seeks the same results as those achieved by HROs, with the exception HPOs are subject to a
higher risk of failure than HROs (Weick & Sutcliffe, 2001). Alternatively, Kolind (2006)
suggests building a new paradigm to help organizations transition into a collaborative
environment is necessary for their survival in todays environment. His model was built on
four pillars: (a) the organization for existence more than for profit-making, (b) real
partnership between management and staff, (c) organization for collaboration, and (d)
leadership based on shared values and not authority and power.
Weick and Sutcliffe (2001) suggest most organizations fail to sustain their
performance because they fail to manage mindfully. They add that organizations can achieve
and maintain their success for a lengthy period of time by manifesting HRT principles.
Incorporating these principles in an organization produces an organization focused on short-
term and long-term outcomes. It produces a workforce preoccupied with failure as they
manage to achieve the efficiency and gain stakeholders desire. Employees of an HRO pride
themselves and find motivation and success in working together as a team and in being a part
of a flexible organization and management. Weick and Roberts (1993) explain that even if
the unexpected occurs, HROs are resilient enough to absorb the shock and remain standing,
unlike many non-HROs that collapse and never rise or rebound again. The reason HROs are
able to function with high reliability, almost always, rests in their ability to enact mental
processes that are more fully developed than those found in organizations concerned with
efficiency, such as HPOs and MOs (Weick & Sutcliffe, 2001). The secret recipe for their
success resides in their ability to manifest the five HRT principles in their operational input.
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Literature Review of HROs
This section provides extensive details on HRO literature. Similar to the discussion
on HPOs, the HRO literature review will address the aspects of the theory that are most
relevant to this study and the main research questions. RSO literature builds on the HPO
theory in the search for a repeatable organizational model that both RSOs and MOs can
emulate to achieve and sustain long-term reliability.
HROs include organizations such as power grid-dispatching centers, nuclear power
plants, hospital emergency departments, and hostage negotiation-teams. These HROs have
been exceptionally successful and able to maintain a high performance and HRO status since
inception because they are able to organize themselves to notice the unexpected in the
making and halt it from development. HPOs, in contrast, pay little attention to small negative
events that grow large enough to destabilize the organization or disable it from being able to
meet the changes and demands enforced upon it by internal and external factors. They do
that because they are preoccupied with success to the extent that it takes away not only an
HPOs ability to see the big picture, but also the ability to detect errors and notice anomalies
in operations.
All organizations are alike in the sense that they all develop unnoticed events that end
up being at odds with the course of business and norms. It is these similarities that are
managed so well in HRO organizations that can be transferred as lessons learned to other
organizations.
History of HROs
HROs beginnings can be traced to James Reason in 1972 and Barry Turner in 1978
(Roe & Schulman, 2008). Their research described the human and organizational factors as
51


systematic producers of technical failures (Roe & Schulman, 2008). However, the work of
Charles Perrow at the Three Mile Island nuclear power plant in 1982 was a key for
establishing the theory (Bigley & Roberts, 2001; La Porte, 1996; La Porte & Rochlin, 1994;
Roe & Schulman, 2008; Shrivastava, Sonpar, & Pazzaglia, 2009; Vaughan, 1999; Vogus &
Welboume, 2003; Weick, 1976, 2004). Perrow (1984) created the Normal Accident Theory
(NAT) that led to the creation of the HRT shortly after NAT was introduced.
History of Normal Accident Theory (NAT)
Perrow (1984) established NAT in the aftermath of the Three Mile Island nuclear
power plant accident. He was asked by Cora Marrett, a former student and government
commissioner, to head a social-science research project to present a non-engineering point of
view (Ford et al., 2003). Perrow (1984) introduced the concept that in technologically
complex systems accidents are unavoidable no matter how prepared an organization may be.
He argues that a normal accident is not just unexpected but actually unnoticed and
incomprehensible for a period of time. He explains that the problem is operators are not as
complex as the system, so it takes them a while to figure it out. However, he states that
operators are not stupid, but rather are facing an impossible situation. What makes this
situation worse, he argues, is the complexity and tight coupling in the system. Alternatively,
he argues that other factors also affect the way in which operators respond to the system. For
example, the organizational structure constituted by the decision-making process within the
organizationwhether it is centralized or decentralizedcan affect the response rate and
type to a potential accident. Ford et al. (2003) explain that micro-managing, normally an
element in a centralized organization is unsatisfactory and can be disastrous. To this end,
they categorize decision-making into three forms: (a) absolute rationality or the basis of how
52


we should think and act; (b) limited rationality from cognitive psychology, where actions
may be justified depending on the context; and (c) social and cultural rationality based on
who we are; we all think and respond differently.
The importance of Perrows early work lies in his identification of two dimensions of
complex systems: (a) interactive complexity and (b) loose/tight coupling. The first dimension
refers to a system in which two or more single failures can interact in an unexpected way
making the entire system vulnerable to normal accidents. The second dimension, loose/tight
coupling, refers to sub-system components that can cause it to fail or enable it to respond to a
failure depending on whether the system is loosely or tightly coupled. Perrow (1984) outlines
four characteristics of a tightly coupled system that are important to this study, especially
when compared with loosely coupled systems (see Appendix E).
To Perrow (1984), organizational complexity refers to the way in which components
of a system interact with one another. This is rather important because it is what complexity
refers to when we are speaking of HROs. So what constitutes a complex system are the
complex interactions when it has (a) unfamiliar, unplanned, or unexpected sequences of
events that could be visible right away, or not immediately comprehensible; (b) design
features such as branching, feedback loops; and (c) opportunities for failures to spread across
subsystems boundaries. A complex system is said to be tightly coupled when it has (a) time-
dependent processes which cannot wait; (b) rigidly ordered processes (a ranking order); (c)
one way to achieve an outcome; and (d) little to no slack time (precision in resource forecast
and usage).
Perrow (1984) concludes that when a system is interactively complex and tightly
coupled, independent failure events may interact in ways that cannot be predicted easily and
53


may spread rapidly throughout the system causing a failure. He believes that the more
technology we employ to correct such a behavior, the more complex the system becomes. At
some point, this complexity causes the organization to become more prone to accidents. For
Perrow (1984), system redundancy is a way to improve the reliability of the system. He adds
systems can be designed safer if interactivity and tightly coupled features are reduced. Roe,
Schulman, Eeten, and Bruijne (2005) disagree with Perrows position on this and instead see
complexity and tight coupling as major organizational resources that ensure reliability. Roe
et al. (2005) believe that they create, enhance, and sustain the skills and options of technology
operators to manage the very fluctuations in real time.
On a structural level, Perrow (1999) explains that while complex and tightly coupled
systems are naturally vulnerable to accidents, difficult structural changes may reduce that
vulnerability. He explains that the organization can be broken down into smaller more
manageable units that are controlled by monitoring links. He argues that designs can be
robust and inelegant rather than just elegant and sensitive. Additionally, he explains that
skepticism should be a part of the structure and it should be implemented through the
development of worse case scenarios. Finally, he encourages feedback loops with
contributions rewarded. However, he emphasizes that external stakeholder involvement is
critical.
Similarly, Levenson, Dulac, Marais, and Carroll (2009) suggest that there are other
ways to increase reliability and safety in complex systems that will often reduce complexity
such as redundancy, the use of protection systems, and the elimination of potential human
error. To this end, Jeffcott et al. (2006) agree and explain that organizational safety culture
and reliability reflects the behaviors and attitudes of employees and how they perform. They
54


further explain that such a belief is guided by organizational practices that an organization
can adjust to positively or negatively. Weick and Sutcliffe (2001) attribute HROs success in
avoiding catastrophes to their ability to act mindfully. Even so, Perrow (1984) points out that
some complex tightly coupled systems manage somehow to remain safe and reliable despite
all odds. Those organizations later became known as HROs.
Perrows (1984) observation was the key that led to the research and discovery of the
HRT. The HRT theory agrees with Perrows notion that you can never be 100% sure you
will remain accident free. However, some organizations, such as nuclear power plants and
hospital emergency roomscomplex and tightly coupled organizationshave remained free
of failure since inception (Weick & Sutcliffe, 2001). The lessons learned from such
organizations hold the key for many organizations facing both threats and opportunities in
todays challenging and demanding business and social environments (Weick & Sutcliffe,
2001).
While Perrow (1984) focuses on explaining the key components of high risk,
complexity, and tight coupling, Shrivastava (1988) explains the human, organizational and
technical aspects of crisis management. In his analysis of industrial crises in three diverse
crises (the Bhopal disaster, the Tylenol poisonings, and the explosion of the space shuttle
Challenger), Shrivastava explains that low employee morale and management conflicts
contributed to carelessness and led to the disasters. Particular to the Bhopal disaster,
Shrivastava (1988) suggests staff reduction resulted in inadequate safety training and sharing
of information, which contributed to the accident and eroded human back-up systems. This is
important because these were failure components seen in HPOs. To prevent such failures,
Fildes and Rose (2004) suggest six crisis-preparation activities that align and directly support
55


the shared HRO characteristics: (a) just culture, (b) early detection of errors, (c) reporting
paths and culture, (d) availability and mobility of resources, (e) strategic adoption, and (f)
deference to expertise.
Both Perrow (1984) and Shrivastava (1988) agree on the importance of
interdependence among organizational units. Interdependence, here, implies employees are
dependent on one another. Roberts (1990) notes when tasks are highly interdependent close
grouping of employees and tight coordination and control enhances reliability. Turner (1976)
suggests that disasters occur when a large complex problem is dealt with by a large number
of employees. Perrow (1984) and Shrivastava (1988) also emphasize the impact of shifting
environments and explain that they could result in conflicting goals, which could increase the
probability of risk. Roberts (1990) agrees with both and suggests simultaneous operations in
hazardous technologies do in fact increase the subjectivity of these organizations to a high
probability of risk. Appendix F and Appendix G summarize a modified version of Perrows
(1984) and Shrivastavas (1988) antecedents to accidents (Perrow, 1984; Roberts, 1990).
History of High Reliability Theory (HRT)
Around the time Perrow created NAT (Shrivastava et al., 2009), the HRO project was
initiated to explore the characteristics of large-complex systems that have performed
consistently at an extraordinary level of safety and productive capacity by beating all
challenges and changes, planned or unplanned, in their environment (La Porte, 1996). The
project was initiated by scholars from two universities: Kaleen Roberts, University of
California, Berkeley, and Herbert Simon, James March, and Karl Weick, University of
Michigan. Researchers were motivated by Perrows (1984) pessimistic view that accidents
are imminent no matter how well an organization is prepared to deal with them. The
56


organizations studied managed to remain accident-free for impressive lengths of time and
were able to build the capacity required to manage the unexpected. The scholars goal was
simply to find out how did these highly-complex organizations, that operate in a demanding
and dangerous environments, managed to sustain such a high performance.
HRO research began investigating reliability-enhancing processes in US Navy carrier
aviation (Rochlin, LaPorte & Roberts, 1987), the Federal Aviation Administrations air traffic
control operations (Schulman, 1993), and commercial nuclear power plants (La Porte &
Consolini, 1991). The initial research questions explored (a) decision-making in HROs, (b)
the technical adaptation and structure of HROs, and (c) culture of HROs (Rochlin, 1996).
Karl Weick was one of the early HRO scholars to suggest the usefulness of culture as
a way to address issues concerning organizational reliability. Weick (1987) states that culture
is important because it allows a simultaneous centralization and decentralization decision-
making process which Perrow (1984) earlier also suggest was very important.
Roe et al. (2005) also support this notion and claim the best way to reduce the risk of
an attack on major infrastructures is by decentralizing the decision-making process. The
most important case studies in HROs include the Cuban Missile Crisis, the Three Mile Island
nuclear incident, the Challenger explosion, the Bhopal chemical leak, the Tenerife air crash,
the Mann Gulch forest fire, the Black Hawk friendly fire incident in Iraq, and the Columbia
explosion (Mannarelli, Roberts, & Bea, 1996; Weick, 1993). The result of this research
established what has come to be known as the principles of the high reliability theory (HRT).
These are widely generalized only in organizations that operate in complex and tightly
coupled environments (e.g. nuclear power plants, air traffic controllers, hospital emergency
rooms, or hostage-negotiation teams).
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NAT vs. HRT Perspectives
There is a fundamental difference between NAT and HRT. NAT suggests that
disasters are the unwanted, but are inevitable consequences of complex socio-technical
systems (Perrow, 1994). In contrast, HRT sees disasters as preventable when certain
characteristics are applied by the organization (Weick & Sutcliffe, 2001). However, it is
important to note that HRT theory states there are no 100% error-free operations. Even so,
Weick and Sutcliffe (2001) argue that errors can be prevented. Homsma et al. (2009) affirm
that the elimination of errors in organizations is impossible but that employees ability to
interact and discuss errors openly, a climate created by HRT thinking, promotes learning, and
thus creates an environment in which further errors can be prevented.
Tucker and Edmondson (2003) suggest the lack of organizational learning from
failures can be explained in three reasons: (a) emphasis on individual vigilance, (b) unit
efficiency concerns, and (c) employee empowerment. Katz-Navon, Naveh, and Stem (2009)
suggest an active learning environment provides organizations and employees with the
opportunity to acquire knowledge by encouraging employees to ask questions, provide
feedback, assess results, and seek innovative solutions through exploration and experiment.
Table 7 presents a summary of how both theories view reliability in complex and tightly-
coupled organizations (La Porte, 1994; Perrow, 1984; Weick & Sutcliffe, 2001).
Sagan (1994) argues that organizational learning required for HRT success is
restricted for reasons such as ambiguity about accident causes, the context of the system, the
human factor, and secrecy between organizations. A heated debate has been going on
between NAT and HRT supporters as to which theory is more accurate. Many attempts to
reconcile both theories failed because of fundamental differences (Shrivastava et al., 2009).
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Table 7
HRT vs. NAT Regarding Reliability in HROs
HRT NAT
Accidents are prevented through good organizational design and management Accidents are inevitable no matter what we do
Reliability is a priority Reliability is one of many competing objectives
Redundancy enhances reliability Redundancy often reduces reliability and safety
Decentralized decision-making needed Organizational contradiction: Decentralization for complexity but centralization for tightly coupled systems
Culture is a source of reliability A military model of intense discipline is compatible with democratic values
Ongoing training and improvements can create high reliability operations Organizations cannot train for events that cannot be depicted
Trial and error learning can be effective but can be supplemented by stimulations Denial of responsibility, faulty reporting cripples learning efforts
While NAT focuses on structure and claims that complex and tightly coupled structures
trigger accidents, HRT focuses on organizational processes. HRT also references
organizational characteristics shared among HROs that can prevent accidents and improve
reliability (Vaughan, 1999). However, in practicality these fundamental differences are non-
falsifiable. Thats because either theory could claim a credit for why or why not an accident
has occurred. For example, in the case of an accident, HRT supporters could claim the
organization stopped being highly reliable and that is why it failed. In contrast, in the case
59


where an accident was avoided, NAT supporters could claim the system was not tightly
coupled or complex enough (Rosa, 2005; Shrivastava et al., 2009).
It is important to note that while complexity and tightly coupled aspects may seem to
increase the risk in such systems, Roe et al. (2005) suggest these same elements convey
reliability advantages to employees in control rooms who seek to restore them in the case of a
catastrophe. Others have gone as far as accusing HRT of being applicable only to high- risk
systems and that its conclusions cannot be generalized to all organizations seeking reliability
(La Porte & Rochlin, 1994). However, for others (Leveson et al., 2009) NAT is better
because it recognized the difficulties from inception. Leveson et al. (2009) suggest an
alternative and stronger way of achieving highly safe systems by presenting an alternative
approach based on systems theory. This approach takes a systemic and integrative view that
provides the organization with ways to connect institutional, organizational, group, and
individual in a system approach.
The debate continued in an effort to resolve this longstanding difference with
Shrivastava et al. (2009) claiming to have resolved the issue. They introduced a temporal
dimension, which puts both NAT and HRT on one continuum but at different points in time.
The model claims that NAT speaks of accidents after they happen while HRT speaks of
accidents before they take place. However, they agree the systems theory approach
introduced earlier still accounts for the conclusions reached by both theories. Also, the
temporal dimension still does not resolve or address the non-falsifiability problem. In
another approach, Bain (1999) argues that both theories should complement one another as
opposed to competing with each other. Bain used the theory of action as a conceptual
framework to explain why employees perform ineffectively and how, when that fact is
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applied to reliability, performance falls short of expectations. Perrow (2009) rejects the time
dimension idea and states that NAT does not say anything about the time dimension that
triggers human failures. He emphasizes that his theory does not focus on the human behavior
and still holds ground for explaining how and why accidents occur.
On November 4, 2009, as part of preparing for the present research, the researcher
interviewed Kathleen Sutcliffe, one of the main HRT scholars. The pioneer and HRO
theorist explained that in all of his recent writings, Perrow is becoming more of an HRO
theorist.
Defining, Measuring, and Validating Reliability
How organizations achieve reliable outcomes on an ongoing basis is a question that
has been answered unevenly in organizational theory (Blatt, Christianson, Sutcliffe, &
Rosenthal, 2006). Reliability has become a worldwide focus for all organizational and
governmental agencies. It has especially become critical in hazardous-technical systems or
HROs for four reasons (Roe & Schulman, 2008): (a) intensifying social dependency on high-
performance hazardous technologies (i.e., nuclear weapons, medical technologies, complex
electrical grids, telecommunication systems, and jet air-craft); (b) large technical systems are
catastrophic and have tight error tolerance; (c) high profile accidents became more common
(i.e., Three Mile Island, Bhopal, Challenger, Columbia, and Chernobyl); and (d) the lash back
from 9/11 and Hurricane Katrina, which intensified interest and concerns about certain
infrastructures in the USA and their ability to deal with catastrophes. For HROs, the
consequences are not just economic in nature but affect the safety of human beings, while the
failure of products or processes in MOs could still have similar consequences (Bergman et
al., 1985). Most organizations experience a logical relationship between results and financial
61


resources. If organizations achieve substantive success, their resources increase or otherwise
decrease affecting their existence and ability to succeed in the future (Banerjee, 2005).
Defining reliability. Reliability for some means the constancy of services (Roe &
Schulman, 2008) and for others the safety of core activities and processes (La Porte, 1996).
Hollnagel (1993) suggests that reliability depends on the lack of unwanted, unanticipated, and
unexplained variance in performance. In HROs, reliability means anticipation (Schulman,
2004) or prediction, which can be addressed through planning and effective system design
and resilience (Vogus & Sutcliffe, 2007), or the ability of an organization to plan for shocks
and rebound from them which can be addressed by coping in real time. Blatt et al. (2006)
challenge this notion and explain that in most cases, respondents accounts revealed the lapse
experienced was variable and unexpected making planning ahead difficult. They suggest
there are limits to the HRO resilience approach to reliability. However, Blatt et al. (2006)
challenge the prevention approach to reliability, citing most respondents counts revealed the
lapse in reliability was not visible, and thus the lapse could not be prevented. However, the
difference in HROs is that they have the resilience to rebound from shocks even if the
unexpected occurs.
In a study that explored the sensemaking processes experienced by a sample of
medical residents around lapses in reliability of patient care, Blatt et al. (2006) reported that
lapses in reliability cannot always be predicted due to the unfolding and shifting nature of
organizational events. Those lapses cannot always be dealt with in real-time, either because
they may not be visible or because psychological and social factors may hinder the actors
abilities to cope. They further classify lapses in reliability into three main categories: (a)
whether or not actors realized a lapse in reliability, (b) whether or not actors have the
62


opportunity to mitigate the lapse, and (c) whether or not the actors took action to mitigate the
lapse. In most organizations, reliability suffers because it is being viewed as a postponed
failure (Busby & Strutt, 2001). Busby and Strutt further explain that failure postponement
reduces attention to reliability for the following reasons: (a) the priority of reliability during
the organizational design process may not be as high especially if time is a constraint, (b) the
future is often discounted, and (c) analysis of reliability can occur last in the design process.
A major determinant of organizational reliability is how much an organization
devalues the miss-specification, miss-estimation, and misunderstanding of things (Schulman,
1996). The more an organizations members care about miss-specification, miss-estimation,
and misunderstanding, the higher the level of reliability achieved (Schulman, 1996).
Studying a nuclear power plant, Schulman (1993) argues that reliability can best be achieved
through the management of fluctuations in important organizational relationships and best
practices but not through organizational invariance.
In engineering, reliability and performance are not as dynamic or vague as those in
HROs. However, they carry the same meaning. Ireson, Coombs, and Moss (1996) define
reliability as the ability or capability of the product to perform the specified function in the
designated environment for a minimum length of time or minimum number of cycles or
events (p. 12). The authors explain that overall system reliability is the product of the
reliability of all of its parts; however, one part in the system could still be reliable while
another is not. Viewing reliability as a process helps define reliability expectations of
customers and improve delivery turnaround time. Ireson et al. (1996) offer the following
reasons why reliability should be managed as a process:
Market changes in demand for high quality and reliability.
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Customer-focused and minimum time-to-market product development.
Product liability incentives because bad products are costly to business.
Regulatory pressure resulting from laws and regulations.
Overall, the importance of reliability stems from the fact that it is equated to
customer satisfaction, and reliability policies provide guidance and remove uncertainty within
the organization. The reliability goal-setting process has to do with breaking down
requirements into manageable work-packages to reinforce the net outcome.
Measuring reliability. In engineering, the most direct way to express and measure
reliability is by how much reliability can bring in per a unit price (Ireson et al., 1996), which
in the end represents return on investment (ROI). In HROs, reliability is measured by the
organizations ability to remain error free, which is managed by improving its ability to detect
errors as they develop. Reliability and safety are viewed as dynamic nonevents that require
ongoing attention and effort. Anything that affects the attention and effort required matters to
the achievement and sustainment of high-performance outcomes (Weick & Sutcliffe, 2001).
One criticism of HRO as a business model is that it does not necessarily provide a
solid reliability measurement tool (Roe & Schulman, 2008; Weick & Sutcliffe, 2001).
However, HRO scholars suggest that the key to measuring high reliability and its fluctuations
is to evaluate risky situations that occur more frequently (Roe & Schulman, 2008). This is
crucial for maintaining reliability as opposed to achieving invariance in organizational
outputs (Roe et al., 2005). This has been demonstrated effectively in HROs over a lengthy
period of time. It has allowed them to achieve and sustain high reliability levels despite the
many challenges in their environment (Weick & Sutcliffe, 2001). Similar levels of reliability
have also been seen in RSOs that manifest the HRO principles (Barrett, 2008).
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Characteristics of HROs
Good management of the unexpected is to be mindful of it (Weick & Sutcliffe,
2001). Organizations such as power grid-dispatching centers, air traffic controller systems,
nuclear aircraft carriers, nuclear power plants, hospital emergency rooms, and hostage-
negotiation teams are places that operate in changing environments yet almost always
manage to operate error free. Because of this unique characteristic, these organizations rarely
fail, achieving that result by being mindful or by noticing the unexpected in the making and
halting its development. Even if they are not totally successful, they are resilient enough to
be able to contain it and manage it better. Because of what they do on the insidenot their
outputthese organizations are great examples of how an organization can manage the
unexpected. Weick and Sutcliffe (2001) provide five hallmarks of HROs that, today, are
considered a successful recipe for identifying and transitioning to an HRO. These hallmarks
also make up the HRT backbone and what the authors refer to as mindfulness processes.
The five hallmarks are centered on two major mindfulness strategies: (a) containment
(preoccupation with failure, reluctance to simplify interpretations, and sensitivity to
operations), and (b) anticipation (commitment to resilience and deference to expertise). It is
worth noting that while other researchers may have discovered additional HRO
characteristics (i.e., Roberts, 1990), these are HRTs known principles.
Preoccupation with failure. While HROs manage to stay highly reliable by
managing to remain error free, they constantly focus on predicting and eliminating errors
rather than merely reacting to them. To them, a near miss is a sign of failure not a sign of
success, nor is it viewed as an attempt for a stable activity system such as those seen in HPOs
or MOs (Reason, 2000). Such an incident is seen as a sudden change in the environment that
65


must be studied and new lessons discovered (Merriam, 2005). The incident is seen as a
coaching moment and an opportunity to better understand what may have gone wrong in the
system so as to be able to halt it in the future, before another incident or accident happens.
This systematicholistic view of the system aims at treating any lapses as a sign that
something is wrong within the system and must be addressed. What explains the functioning
of a small simple system can also explain a large complex system (Clarke, 2003).
Reluctance to simplify interpretations. This refers to the need to avoid ignoring
detailed explanations for difficulties and problems an organization faces. It does not refer to
creating a complex large system to maintain reliability. The goal here is to create a state of
mind in every employee that captures the big picture (Weick & Sutcliffe, 2001). Many
mangers fail because of their inability to see the big picture (Bolman & Deal, 1991). HROs,
unlike many other organizations, operate in an environment hard to predict, unstable,
unknowable, and complex, and thus workers and managers simplify less to see the big
picture. What occupies their minds most is the fact that they acknowledge they can fail any
time because of something unplanned or unexpected. Equipped with this mindset, employees
of an HRO are universal in that they are encouraged to think out of the box and reach as far
out as possible to understand their environment and watch for signs of failure. HROs reward
this kind of behavior and error reporting. What this does is help HROs build teams and
encourage teamwork, primary requirements for managing the unexpected in a complex
environment (Weick & Sutcliffe, 2001).
Sensitivity to operations. HRO leaders recognize HROs are open complex systems
influenced by the inflow and outflow of information (Clarke, 2003). Thus, they keep
constant and strong contact between their employees, especially front-line employees, to
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make sure anomalies and problems are quickly identified and dealt with (Weick & Sutcliffe,
2001). Tucker and Edmondson (2003) note that front-line employees are positioned well to
help their organizations learn by being able to suggest changes in the processes and activities.
The HRO model views unexpected events as events that have existed for some time in
loopholes without however causing a major accident. The loopholes consist of defects in
operations in various units. The goal of an HRO in this arena is to ensure that employees
have a comprehensive situational awareness that helps them, as they approach issues and
define problems, apply total quality improvements and make other adjustments to ensure
errors are prevented. The main point is to help every employee see the big picture and
develop a complete situational awareness of the system. This is not a component of what
classical or HPO organizations strive to accomplish (Weick & Sutcliffe, 2001).
Commitment to resilience. Commitment to resilience, one of the most important
features of HROs, is the ability to quickly and instantly engage their employees and resources
to contain errors or other difficulties that may be seen as potential problems. HROs never
take it for granted that the system will never fail, just because they have obvious safeguards
in place. They indeed plan for such a failure by conducting ongoing training, assessments,
and stimulations that require the HRO employees to work with one another and practice a
situational response to incidents or accidents. For HROs, learning from near misses,
developing the skills to bounce back, and containing problems or errors so that the system is
not entirely disabled are keys to survival. According to Weick and Sutcliffe (2001),
resilience is both keeping errors small and improving workarounds to keeping the systems
functioning.
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Deference to expertise. The HRO culture is one that influences employees to work
as a team and refer to experts when a situation requires it. The organizations hierarchy is
rather de-emphasized to allow open and smooth communication channels between all levels
of the organization (Weick & Sutcliffe, 2001). Because of this structure, decision-making in
HROs is pushed vertically and horizontally, so a decision could be made by any expert
regardless of rank. This is not to say that HROs are in high tempo 24/7. HROs do indeed
differentiate between normal times, high-tempo times, and emergencies. Depending on
which status the organization is in, the decision is either centralized or decentralized. In
contrast, employees in MOs do not communicate errors if (a) they are uncertain about others
reaction, (b) they dont want to be blamed, or (c) they fear damaging their careers (Homsma
et al., 2009).
An important characteristic of HROs also is their ability to create the interaction
necessary between their members to maintain reliable operations and reduce the risk of
catastrophe (Barrett, et al., 2006; Weick & Sutcliffe, 2001). When this happens,
communication among members of an organization is strengthened because of the creation of
a shared employee conceptualization of the organizations mission. Several researchers
(Venette, 2003; Weick & Sutcliffe, 2001) explain self-efficacy and organizational-risk
response are important factors in managing the unexpected. Banerjee (2005) affirms
organizations begin to experience problems when employees fail to comprehend the complex
interactions among the organizations units and subunits. Tables 8a and 8b provide a
summary of HRO characteristics in the literature.
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Table 8a
Characteristics of HROs in the Literature 1989-1997
1989 1993 1990a,
Roberts Roberts & Libuser Roberts
Command by exception Process auditing Culture of trust and shared
Redundant operations Reward system values
Firm situational analysis Quality assurance Risk mitigating and communication processes
Risk management corrections Distributed decision- making process
Table 8b
Characteristics of HROs in the Literature 2001-2008
2001 Weick & Sutcliff 2005 Burke, Wilson, & Salas 2008 Roe & Schulman 2008 Stringfield, Reynolds, & Schaffer
Preoccupation with failure Reluctance to simplify Sensitivity to operations Commitment to resilience Deference to expertise Hyper- complexity Tightly coupled Extreme hierarchical differentiation System redundancy Accountability Timely feedback Compressed time factors Synchronized outcomes High technical competence High performance and close oversight Constant search for improvement Hazard-driven adaptation to ensure safety High pressures, incentives, and shared expectations Flexible authority patterns Positive, design-based redundancy Social context Clear and shared goals An ongoing alertness to reliability lapses Boundary-less environment Error reporting culture Recruit new staff at all levels Training and retaining Ongoing performance evaluation Hierarchical but horizontal (flat) structure Employee trust
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As Weick and Sutcliffe (2001) have done, other members of the Berkeley group also
spent a lengthy time looking at other HROs to define their characteristics. Taken together, all
HRO characteristics are related and are elements of the mindfulness required to help HROs
manage the unexpected and remain reliable and error free. Weick and Sutcliffe (2001)
explain HROs are able to manage the unexpected, despite of the fact they are constantly
exposed to uncertain environments, by developing the capability to be mindful.
Baneijee (2005) explains that no one denies that most recent large scale disasters
such as Mann-Gluch fire disaster in Montana, the Bhopal chemical plant explosion, the Three
Mile Island nuclear accident, and the Tenerife air crashes of a KLM 747 and a Pan-Am 747
jumbo jet, are all the result of small undesired events that became linked and exacerbated in
an unexpected way. Equipped with mindfulness, HROs catch the unexpected in the making,
early on, and mitigate the situation. Their ability to deal with the unexpected is largely
dependent on the organizations structure that developed before the crisis arrives (Lagadec,
1997). Following are containment strategies in HROs (Weick & Sutcliffe, 2001):
HROs build capabilities to cope with errors that occurred as much as they plan for
events that havent occurred.
HROs develop capabilities for mindfulness, swift learning, and flexibility.
HROs adopt a wide range of cure rather than prevention.
HROs encourage employees to make knowledge about the system transparent and
available for other employees.
HROs establish pockets of resilience through uncommitted resources.
HROs create a set of operating dynamics that shifts decision-making and leadership
to the subject matter experts.
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It is highly important to note that the HRO literature emphasizes that plans, operating
procedures, and the like have effects that run exactly against the processes of mindfulness
(Weick & Sutcliffe, 2001). Because they embody expectations, they narrow employees
perception and ability to see the big picture. This is a critical difference between HROs and
HPOs or MOs that depend on contingency planning.
Complexity in HROs
Complexity in HROs refers to technological risk and reliability. HROs are defined
by their potential to cause a failure that leads to a catastrophe (Roberts, 1990a). If the
potential is high but the number of failures is low, the organization can be classified as an
HRO. Perrow (1984) defines a complex organization as an organization that is tightly
coupled and interactively connected. Weick and Sutcliffe (2001) define HROs as
organizations that are technologically complex and tightly coupled.
HRO Relevance to Non-HROs
What type of an organization may benefit from implementing the HRO hallmarks is
rather irrelevant. Organizations of all types could still suffer other, equal if not far exceeding,
consequences (Weick & Sutcliffe, 2001) compared to loss of lives in an HRO. The recent
collapse of Enron, WorldCom, and many other large companies are examples of
organizations that collapsed and caused major financial, social, and political catastrophes.
HRO theory explains that the lack of mindfulness and their inability to predict or manage the
unexpected contributed largely to their collapse. What HROs pay attention to, how to
operationalize their definition of work, and how they struggle to sustain reliability are lessons
that could be applied in MOs. Whether were speaking of a grocery store chain or a multi-
billion dollar organization, all organizations are alike in the sense they develop a generally
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accepted culture that helps them identify with the outside world (Weick & Sutcliffe, 2001).
This culture also acts as a lens through which they see the world and develop norms, rules,
procedures, guidelines, and job descriptions. These altogether make up a quality control plan
to help an organization define events that are at odds with its belief. This in turn helps the
organization prepare to deal with the unexpected which in turn sustains the organizational
reliability it expects to produce and maintain.
Decision Making in HROs
In most organizations and decision-making theories, the decision-making process
may have a single set of norms (Roberts, Stout, & Halpem, 1994). However, decision-
making in HROs is characterized by the need for speed and for accuracy (Bedeian &
Zammuto, 1991; Halpem, 1989) and by being flexible and dispersed throughout the
organization (La Porte, 1996). This is because HROs functioning is so critically dependent
on understanding that process. A failure in making the right decision could cause a major
catastrophe (Halpem, 1989).
The standard description of decision-making is to (a) identify goals, (b) search for
alternative solutions, (c) account for negative consequences, (d) evaluate available options,
and (e) select the best alternative approach (Anderson, 1983). Decisions can either be made
with a conscious or a non-conscious state of awareness. It depends on information available
and whether or not decision-makers have developed the proper situational awareness in their
context (Heald & Heald, 1991). When a decision needs to be made, the employee with the
most knowledge, the expert, gets to make it no matter what his or her rank (Weick &
Sutcliffe, 2001). Once a decision is determined, it is often executed very quickly, based on
information available and within a little chance for review, recovery, or alteration (La Porte,
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1996; Perrow, 1994). This is another reason why HROs focus on ensuring employees across
the organization are comfortable talking about and reporting errors of all kinds. This is
absolutely critical because most errors made in organizations are made by human beings
(Zhao & Olivera, 2006). In fact, an HRO culture is one that rewards the reporting of errors
(La Porte, 1996; Weick & Sutcliffe, 2001). Roberts et al. (1994) note that HROs have four
important characteristics that affect the decision-making process: (a) technologically
complex, (b) technology is highly interdependent, (c) high risk, and (d) error occurrence is
rare.
Two important definitions are related to the decision-making process in any
organization (Bedeian & Zammuto, 1991): centralization, which refers to the level and degree
of delegating the decision-making process to lower levels in organizations and,
decentralization, which refers to the engagement of all levels in the organization in the
decision-making process. Both of these decision-making models are used today. However,
centralized decision-making is used mostly in organizations with a few hierarchies, such as
small businesses. The larger the organization, the more flexible it should be and thus the
decision-making model should be decentralized.
Traditionally, the decision-making process has been characterized by being
centralized and mostly associated with and supported structural feature in a bureaucratic
adaptation (Hart, Rosenthal, & Kouzmin, 1993). This dates back to Webers theory of
bureaucracy (Roberts et al., 1994). Especially, under time pressure the most trusted and
experienced informal management makes the call (Hart et al., 1993). However, decision-
making centralization is not desirable. Both centralization and tight coupling of operations
may cause a liability in the management of a crisis. It could also disrupt parts of the system
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or trigger multiple component failures (Hart et al., 1993). HROs are flexible organizations.
As a result, they can centralize or decentralize based on whats needed (Weick & Sutcliffe,
2001). According to Hart et al. (1993), two factors contribute to informal decentralization
(Hart et al., 1993): (a) time pressure and (b) overload at the central level. Alternatively, Hart
et al. argue that formal decentralization may occur by anticipation of vulnerabilities. It is
though worth noting that either model has advantages (Bedeian & Zammuto, 1991).
Centralized decision-making has uniformity in decisions because less planning is required. In
comparison, in decentralized decision-making decisions are quicker.
Achieving High Reliability in HROs
HROs are developed through the efforts of individuals teaming up to work together
for the purpose of analyzing near misses or incidents that may undermine their organizations
health. Such organizations manage the unexpected by successfully addressing the variations
and errors that occur (Beyea, 2005). Tucker and Edmondson (2003) identify two types of
process failure: (a) problems and (b) errors. RSOs enact a number of processes to improve
their ability to predict and manage the problems and errors (Weick & Sutcliffe, 2001). Tables
9a and 9b provide details of the literature review on how HROs are able to manage for higher
and sustainable levels of reliability.
Leadership, Teamwork, and Trust in HROs
As mankind evolved, the topic of leadership became a matter of interest. As many
scholars and business leaders asserted over the years, leadership is not a gene that certain
people inherit and keep within their family or a complex code that cant be deciphered
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Table 9a
How HROs Manage for Reliability by Author 1990-2001
1990 1990 1996 2000 2001 2001
Guy Roberts Babb & Ammons. Datnow & Stringfield Bigley & Roberts Weick & Sutcliffe
Simultaneous emphasis on cultural norms, individual involvement, communication at all levels, and strong consensus for flexibility Maximizing values of all personnel Creating redundancy Creating a can-do" behavior Remaining flexible and innovative Extensive training and simulation Redundant assignments Delegation of responsibility Active use of multiple information sources System flexibility Tight job specifications Redundancy Effective c ommunic ations Thorough training Extensive recruiting Training and retraining Performance evaluations Design flexibility Place values in supervisors Focus on long-term efficiency Structuring mechanisms Constrained improvisation Cognition management methods Manage the unexpected Informed culture Conduct incident reviews regularly Situational awareness Treat near misses as a sign of failure Create a vigilant culture Create a culture that encourages variety in employees work Sensitive to operations


Table 9b
How HR Os Manage for Reliability by Author 2Q05-20QS
2005 2006 2007 2008
Beyea Frankel, Leonard. & Denham Anand & Daft Stnngfield et al.
Successfully addie ss the variations and errors that occur Fan and just culture Leadership engagement through "Walkarounds Systemic and reinforced training and effective communication Design structures in advance so that roles and routines are established Devise guidelines to ease and speed the process of resource deployment and alteration Establish the necessaiy protocols that will foster the development and use of the proper mental models Actively discourage freelancing so that employees develop the capacity to always develop their cognitive capacity Training and renaming to ensure operational readiness and effective performance C onduct frequent needs and performance assessments Establish an interorganizational program to ensure appropriate coordination between organizations m case of an emergency Shared finite number of goals The centrality of data and data analysis Standard operating procedures Seek best practice so that teachers acquire the necessary skills Off-Site residential in which each school shares examples of what works best m then context Skillfully manage leadership successions in case of a sudden change Managing in a cyclical effect to ensure a smooth and effective transition


by ordinary people (Northouse, 2007). In todays constantly changing world, the role of a
leader is essential. Leaders of an organization are a core asset that contributes directly to the
enactment of the organizations creativeness and innovation skills, which improve
effectiveness, efficiency, and create new opportunities (Thompson & Heron, 2005). What
leaders think, say, do, and how they present themselves to us as human beings affects our
bottom-line, because they influence the way we behave, act and perform (Boyatzis & McKee,
2005a). Datnow and Stringfield (2000) found that reform implementation faltered when
lacking leaders participation. Even so, successful reforms are not the work of individuals or
organizations acting alone but rather the result of stakeholder involvement.
Leadership. It is a process whereby an individual influences a group of individuals
to achieve a common goal through an observable set of skills and abilities (Northouse, 2007).
Leadership is not limited to predefined individuals, race, religion, sex, color, height, or age.
The concept of leadership evokes images of bold, forthright action by individuals who
possess a clear vision of what should be done (Boyatzis & McKee, 2005a).
Unlike HPOs, the HRO literature does not directly address leadership. Rather, it is
focused on the organization as a collective mind. However, the literature recognizes that
leaders play a major role in structuring for high-reliability outcomes and the culture that
fosters those outcomes (Kerfoot, 2005; Roe et al., 2005; Stralen, 2008; Weick, 1987; Weick
& Sutcliffe, 2001). Frankel et al. (2006) affirm leadership as the single most important
success factor in organizational reliability, accountability, ability, and awareness. This is
because leaders drive values, values drive behaviors, and behaviors drive performance.
Kerfoot (2007) argues that managers are keys to building HROs. She explains that they
become the powerhouse that insures consistency between the different levels of the
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organization. Ford et al. (2003) agree and explain that managers search for the kind of
knowledge that will help improve the organizational performance. Clarke and Ward (2006)
also support this notion, and explain that management practices are associated with improved
safety in the organization. Frankel et al. (2006) claim that leaders are the ones who are able
to manage the facilitation and creation of fair and just culture and team behavior, which both
lead to organizational reliability. This requires three components: (a) visible and consistent
leadership involvement, (b) team leaders who are able to flatten the organization and improve
communication and decision-making, and (c) the employment of tools and behaviors that
improve teamwork.
Teamwork. Teamwork is a critical component of HROs (Baker et al., 2006). A
team can be defined as a group of two or more employees with specific roles who perform
interdependent tasks and share a common goal and object (Baker et al., 2006). Because
organizations are dynamic and unstable, the importance of teamwork is rising. In fact,
teamwork is an essential HRO component (Baker et al., 2006). Teamwork has also been
identified as an important element in error reduction (Morey et al., 2002). Sharon (1999)
argues that intergroup relationships are important for teamwork but also for building trust and
understanding between the different organizational levels, both of which form ground for a
reliable culture. Roth, Multer, & Raslear (2006) agree and suggest that teamwork play a
significant role in improving shared awareness, a characteristic that leads to high reliability.
Trust. Workplace trust has been identified as important to reliability (Conchie,
Donald, & Taylor, 2006; Cox, Jones, & Collinson, 2006). In a study that examined the
importance of trust relations and their impact on reliability, Cox et al. (2006) suggests that
trust encouraged individuals to take responsibility for safety within the organization and to
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develop and challenge culture. Schobel (2009) claims that trust has positive effects on safety
and reliability, and detrimental effects have to be considered in the analysis of trust. Three
trust beliefs were discussed: (a) beliefs based on shared values and norms, (b) institution-
based beliefs, and (c) beliefs based on system reliability. Frankel et al. (2006) explain that
improvements in the healthcare industry will depend on the ability to promote excellent
teamwork and effective communication. They present two ways in which this can be
achieved: (a) the employment of critical tools and behaviors that support collaborative work
and (b) the use of medical simulation to improve performance.
Zand (1972) also concludes that significant differences exist between the group with
the high-trust and the group with the low-trust in terms of goal clarification, the reality of
knowledge and information exchanged, and the commitment of managers to provide
solutions. He reports that when a group works on a problem, two concerns come up: (a) the
problem itself and (b) how the members relate to one another. Therefore, he conceptualizes
trust as a behavior that directly impacts (a) information reporting, (b) mutuality of influence,
(c) promotes self-control, and (d) eliminates abuse of the vulnerabilities of other members.
Clarke and Ward (2006) suggest there is evidence to suggest the level of trust in managers,
impacts performance. Both trust and fairness have a direct impact on organizational
citizenship behavior. Similarly, Jeffcott et al. (2006) report evidence that trust improves
organizational functions such as (a) job satisfaction, (b) group cohesion, and (c)
organizational effectiveness. However, many agree that trust is a multidimensional concept
reflecting a number of elements such as values, attitudes and or sociocultural references.
Thus, they argue that trust is important, but as a product of individuals acting in an
organizational context where trust is a set of attitudes and expectancies about other people.
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They add this is why trust is critical in organizations with high risk such as HROs. Overall,
research within HROs concerning trust is still underdeveloped (Conchie et al., 2006; Cox et
al., 2006; Jeffcott et al., 2006).
Culture as a Source of Reliability in HROs
The culture of an organization is comprised of its values, attitudes, and beliefs.
Those beliefs are how employees build their perceptions and identify with the outside world
(Jeffcott et al., 2006; Schein, 1993; Weick & Sutcliffe, 2001). Culture manifests itself
through three levels: (a) the level of deep tacit assumptions, (b) the level of espoused values,
and (c) the level of day-to-day behavior that represents a complex compromise between the
first two levels (Schein, 1993). Schein (1996) defines an organizational culture that has six
formal properties: (a) shared basic assumptions, (b) that are invented, discovered, or
developed by a group, (c) learns to cope with its problem of external adaptation, (d) have
worked well enough to be considered valid, (e) can be taught, and (f) the correct way to
perceive the world.
One of the earliest papers written about culture as a source of reliability in HROs was
Weicks (1987). He argues that accidents occur because the humans who operate and
manage complex systems are not sufficiently complex to sense and anticipate problems. He
asserts that the answer lies in the organizations culture. He also argues that when
environments become uncertain, the first thing people do is try to make sense of whats
happening. At this point, people either take action to slow the process down and create time
to think rationally or label the change instantly in order to focus on the most pressing issue.
In either case, the issue of sensemaking is a matter of culture.
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Drawing on the case of a coal-mine disaster in Australia, Hopkins (1999) suggests
that disasters are preceded by warning signs which are ignored or missed because of cultural
factors. He suggests two sets of cultural factors that prevent appropriate responses to warning
signs: (a) hierarchy of knowledge and (b) a culture of denial. He agrees with Weick (1987)
and suggests only culture can resolve such issues and differences. Reason (1998) describes a
culture as one that fosters trust and builds a climate in which employees are encouraged to
share information and report errors. He suggests a no-blame culture is undesirable because as
the level of errors increases and rules are bent, employee trust declines and management
creditability will be on the line. He proposes the creation of a just culture in which a clear
line is set and all organizational members know their limits. Figure 2 is an attempt to depict
how culture in HROs enables employees to avoid catastrophes and manage to achieve high
reliability. In this depiction, teamwork, trust between the team members, process
redundancies, and the decision-making processes (centralized/decentralized) are four
elements that contribute to reliability outcomes seen in HROs. Such issues become more
important in HROs, because they are a system that requires both centralization and
decentralization decision-making processes. Culture can then impose an order and serve as a
substitute for centralization.
Researching how culture acts as a source of reliability in the nuclear submarine, an
HRO, Bierly and Spender (1995) argue that culture interacts with and supports formal
structure and thereby produces high reliability. They add that in effective organizations
culture and formality co-exists, while Wilkins and Ouchi (1983) suggest that culture is not
directly related to efficiency in the entire organization, because of control issues and the
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Teamwork
Figure 2. Elements of Reliability Culture in HROs
difference between local organizations culture and that of the more generally shared
background cultures. Instead, they suggest culture will improve reliability and performance
in conditions such as ambiguity, complexity, and interdependence. To achieve high
reliability in hospitals, Franket et al. (2006) recommend just culture principles, teamwork
training, and leadership Walkrounds. Fildes and Rose (2004) agree and suggest the culture of
an organization should be one that encourages employees to discuss all topics no matter how
sensitive they may be without fear of retaliation in any shape or form.
Culture is rather important in shaping a good safety performance and reliability
within HROs (Cox et al., 2006; Kerfoot, 2005). Thus, mindfulness, the backbone of any
HRO, must be treated as an element of culture as well as a process (Weick, 1987). This
means that in order to manage the unexpected, mindfulness must be integrated into the
organizations values, expectations, and norms. This creates a mindful culture that resembles
an informed safety culture. HRO theorists build on Reasons (1998) work and suggest a
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